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With the Compliments of the 

Joint War Committee of the 'British 

T^d Cross Society gf the Order of 

St. John of Jerusalem in England 

83 Vail Mall, London, S.ff.t. 











H. D. GILLIES, C.B.E., F.R.G.S. 



























I HAVE had the pleasure of watching Major Gillies's plastic work since its initiation 
at the Cambridge Hospital at Aldershot, and later at the Queen's Hospital 
at Sidcup, where he and his British colleagues competed so cordially and so 
successfully with the surgeons from the Dominions in their efforts to restore 
the disfigured faces of the wounded to their normal form. 

It was largely due to him that such rapid progress was effected in this 
special and difficult form of surgery, of which little or nothing was known before 
the war. Methods were employed and scrapped with great rapidity as im- 
provements were devised. 

It would be difficult to exaggerate the excellence of the work that was 
done by the several surgeons. Advantage was taken of it by many Americans 
and others, who profited greatly from observing the methods of treatment 
that had been developed there. 

This book, which is so handsomely illustrated, gives a very thorough account 
of the many novel procedures which have been devised or elaborated at the 
Queen's Hospital. It will afford an excellent basis for much civil work, and 
I trust that special departments for plastic surgery will be started at the several 
teaching hospitals, and that means will be taken to secure the services of those 
surgeons who have had such wonderful opportunities to perfect themselves 
in this special work. It is not sufficiently recognised how readily the skill de- 
veloped in this branch of war surgery is directly applicable to the relief of dis- 
figurements met with in civil life. Ugly scars resulting from burns and accidents, 
deformities of the nose and lips, hare lip and cleft palate, abnormal protrusion 
or ill development of the mandible, moles, port- wine stains, all abound, and are 
not only the constant source of the greatest distress and anguish, but materially 
lower the market value of the individual. There is also a vast field in the oblitera- 
tion of marks of operative interference, such as removal of malignant growths. 

This book, written by so skilled and experienced an operator as Major 
Gillies, is invaluable to every general surgeon as well as to the plastic specialist. 

I would also like to congratulate the publishers on the excellent manner 
in which they have produced this volume. 


September 1919. 



PLASTIC Surgery of the Face is not a new development. Surgeons of all civilised 
and some uncivilised countries have from time to time evolved methods of 
repair for various disfigurements. 

But not until the organisation of the new home Medical Service necessitated 
by the late war, with the need for refinement in the matter of segregation of 
cases in special hospitals so ably met by Lieut.-General Sir Alfred Keogh, our 
late Director-General, has there been opportunity for anything but disjointed 
study in this department of surgery. 

In the later development of the work, the continuity of research was main- 
tained by facilities afforded by his successor, Sir John Goodwin, for the retention 
of the specially trained staff, in spite of the difficulties caused by the growing 
shortage of medical officers. 

The author wishes to place on record his thanks to Major-Generals Sir 
Anthony Bowlby and Sir George Makins, and Sir Frank Colyer, who, in their 
capacity as consultants, laid before the Director-General the importance of 
organising means for the intensive study of this special branch of reparative 

The work on which this book is founded began in January 1916, at the 
Cambridge Hospital, Aldershot, where, under the stimulus and able direction 
of Colonel Sir W. Arbuthnot Lane, the treatment of war injuries of the face 
and jaw was studied under suitable conditions in wards earmarked for the 

The author had the advantage there of co-operating with Captain L. A. B. 
King, L.D.S., attached R.A.M.C., whose help as Chief Dental Surgeon through 
that stern period of doubt, trial, and error was invaluable. The influence of 
his work is still evident in our treatment of jaw injuries to-day. 

A rapid increase in the scope of the work led to the removal of the hospital 
to Sidcup, where, thanks to the sympathy and energy of Colonel Sir William 
Arbuthnot Lane, Lieut. -Colonel J. 11. Colvin, and Major Waldron, C.A.M-C., 

Plastic Surgery of the Face 
by H.D. Gillies, Oxford, 
University Press, 1920. 


it was placed on an Imperial basis. The collection of the cases of facial injuries 
from the British, Canadian, Australian, and New Zealand forces in one hospital 
under their own medical officers has proved a factor of prime importance in 
the improvement of methods of treatment. 

Major Waldron and Captain Risdon (Canadian Section), Colonel Xewland, 
D.S.O. (Australian Section), and Major Pickeril, O.B.E. (New Zealand Section), 
and the officers serving with them, joined heartily in friendly rivalry and healthy 
competition, to the great benefit of these poor mutiles. 

Further, with the arrival of American surgeons in 1918 under Colonel Vilray 
P. Blair, M.R.C.U.S.A., our wounded had call upon surgical, skill from the 
whole Anglo-Saxon race. Each surgeon had the assistance of one or more 
colleagues from the New World, to their mutual advantage. 

NYcdless to say, the author realises his indebtedness to the numerous visiting 
and consulting surgeons who from time to time have encouraged him by their 

The knowledge of their interest and good-will has been a most powerful 
stimulus towards perseverance in times when difficulties appeared insurmount- 
able. He wishes particularly to thank Sir W. Arbuthnot Lane, Sir Francis 
Farmer, and Sir Frank Colyer, among consultants ; and, among his British 
colleagues, Major G. C. Chubb, Captains C. F. Rumsey, the late E. G. Robertson, 
F. E. Sprawson, J. L. Aymard, R. Montgomery, H. C. Malleson, and A. L. Fraser 
in the earlier part of the work, and later Captain T. P. Kilner, T. Jackson, and 
Majors H. Bedford Russell and J. J. M. Shaw, M.C. 

In particular, the stimulus of co-operation with Major Seccombe Hett has 
considerably advanced the treatment of injuries to the nose ; while the pioneer 
work of Captain King on the jaw has been maintained and further developed 
by Captain W. Kelsey Fry, M.C., R.A.M.C., Chief Dental Surgeon, who has 
written a chapter on the use of Prostheses in this work. In this connection the 
work of Valadier and Kasanjian in France has been of great service in the 
improvement of the treatment of jaw wounds. I am indebted to the former 
for many photographs of the original conditions, and to both for the stimula- 
tion of their work and for much kindly encouragement. 

Among many American colleagues Captain Ferris Smith has shown himself 
the most constructive critic the author has had the pleasure of knowing. He 
was of great assistance in the preparation of the early proofs of this work. 

Not a small feature in the development of this work is the compila- 
tion of case records. The foundation of the graphic method of recording 
these cases lies to the credit of Professor H. Tonks (Slade Professor), many 
of whose diagrams and photographs of his remarkable pastel drawings adorn 
these pages. 


Unfortunately, his other duties forbade his taking as large a part in the 
work as he and we ourselves could have wished. Latterly, his work has 
been ably carried on by Mr. Sidney Hornswick, who, on his own initiative, 
has considerably improved and standardised methods of recording flap 

The compilation of notes in the early part of our work was carried on 
voluntarily by Mr. Thomas Pope. The author cannot sufficiently thank him 
for the sterling value of his work and the loyalty with which he persevered 
at his self-appointed task through two full and difficult years. 

Lieutenant J. Edwards has not only been responsible for the preparation 
of routine plaster-cast records, but for a very important part of our work, 
the reconstruction of features on the casts as a preliminary to surgical 

Herein, guided by the surgeon in the matter of surgical possibilities, he 
strives, sometimes for the ideal, more often for the best possible surgical com- 
promise ; and his work calls for constructive imagination of a very high 
order. Where chances of surgical repair are not evident he co-operates with 
Captain Fry in the provision of as perfect a mechanical restoration as 

In the X-ray Department Captain H. Mulrea Johnston has displayed great 
ingenuity and resource in evolving standard positions for radiographic 
records, particularly of jaw injuries. Latterly, his place has been ably taken 
by Captain R. A. C. Rigby. 

The majority of the photographic figures in the book have been prepared 
by Mr. Sidney Walbridge. Their excellence speaks for itself, but gives no 
idea of the time and care this late N.C.O. has devoted to ensuring that they 
shall be an honest and true record. He has had to suborn his art to this end, 
sternly suppressing the temptation to manipulate the lighting or retouch the 

The work of correcting later proofs has been kindly undertaken by my 
colleague, Mr. H. Bedford Russell. The heavy secretarial work has been chiefly 
performed by the author's patients (for the most part E. J. Greenaway ; partly 
also R. W. D. Seymour), who have stuck to their task with persistent, cheerful 
loyalty, in the intervals between their operations. 

The author takes this opportunity of thanking his publishers for their oft- 
tried leniency in regard to delays in the production of " copy." In extenuation, 
he would plead a strong penchant for laying aside the pen in favour of the 
scalpel whenever a plastic problem presented itself. 

Above all, the author cannot adequately express what he owes to the loyal 
co-operation and assistance of the medical officers surgeons, physicians, and 


ana-sthetists alike and the Matron, and the theatre- and ward-nursing staffs 
of this hospital, whose shoulders have borne the brunt of the work. Assiduous 
and intelligent care in the after-treatment of these eases is a prime necessity, 
and calls for the highest standard of watchful skill. 

Finally, the author wishes to thank Lieut. -Colonel J. R. Colvin, Com- 
mandant of the Queen's Hospital, for his unfailing help and fairness of treatment 
throughout two long years. His powers of organisation and ready grasp of 
the situation have alone rendered possible the continuity of the work in times 
of stress. 

H. D. G. 

February 1920. 






REPAIR OF THE CHEEK . . . . . . . . .37 








INJURIES OF THE NOSE ....... .211 


INJURIES TO THE PINNA ......... 381 



INDEX 401 



THE origin of plastic surgery is of the greatest antiquity. From time 
i mmemorial rhinoplasty has been performed in India for the relief of the dis- 
figurement caused by punitive mutilation of the nose. Two methods appear 
to have been employed, though the forehead-flap is the only one the use of 
which has survived in India to this day. 

A method embodying the use of cheek-flaps is described in the Ayurveda, 
the sacred medical record of the Hindoos, but it has had to yield to the forehead- 
flap method a striking parallel to what has occurred in Europe in the last 
few centuries. The French (or German) cheek-flap method has been relegated 
to the lumber-room of surgery, and a development of the Indian method, which 
includes the important improvements evolved by Keegan and Smith, has pride 
of place Jx^djiy. 

In perusing the literature of this subject, one is struck chiefly with the 
lack of appreciation of the need for a lining membrane for all mucous-lined 
cavities. Not until Keegan's time was it given any prominence, and perhaps 
even he did not appraise it at its true value. And so it is that the various 
classical methods take their name from the covering flap employed. In actual 
fact, except that forehead skin most closely resembles nose skin, the origin of the 
covering is the least important part. 

The Italian method, which originated apparently in Sicily about 1415 
and was developed by Tagliacozzi in Italy forty years later, consists in the 
transference of skin for a nose-covering from the patient's own arm, in two 
stages, the patient being immured in a fixation apparatus while the flap takes. 
This method was feasible in those stern times, but the more than irksome fixation 
is not tolerated by the modern patient, and it has been discarded. The principle 
on which it is based, however, is of wide application, and a modification of it, 
the author's tube-pedicle method, is in routine use for some of our operations. 

As in rhinoplasty, so in the rest of present-day plastic work, the principles 
laid down by the fathers of surgery are found still to be of general application. 
There is hardly an operation hardly a single flap in use to-day that has 
not been suggested a hundred years ago. But our work is original in that all 


of it has had to be built up again de novo. It does not fall to the lot of every 
surgeon to see even one chciloplasty in his training. 

The earlier months, then, were spent in a very thorough trial of the then 
known methods. It has been illuminating to discover the impracticability 
of many of these, which would appear to have been put forward on the study 
of one case only, or even on purely theoretical grounds. Among the sponsors 
of really practicable methods the names of Tagliacozzi, Nelaton, Keegan, and 
Smith stand out prominently. 


It is the author's aim here to discuss principles in the order of their ap- 
plication in a given case. They will thus be dealt with, in the following order : 


EARLY TREATMENT. General Technique. 


1. Lining Membrane. Suture. 

2. Contour and Supports. Dressings. 

3. Covering Tissues. After Treatment. 


The history of the injury is obtained, together with any existing record 
of the early condition, and if possible of the condition prior to injury. It is 
of importance also to obtain information as to the presence of luctic or tuber- 
cular taint, and as to the patient's healing powers as shown in former operations. 


The majority of failures in plastic surgery are due to errors the commission 
of which would lead to failure in any form of surgery. Thus, mistakes in diagnosis 
due to inadequate examination are perhaps the commonest cause of indifferent 
treatment. This element of difficulty in diagnosis may not at first sight be 
obvious. The word diagnosis in this work is used in its literal sense, namely, 
to mean a thorough knowledge of the condition present i.e. the exact loss in 
terms of anatomical structure. 

The routine examination of our cases, with preparation of records of the 
condition on admission, occupies nearly a week ; but the time so lost is regained 
a hundredfold. The examination merely of the surface of. the lesion, simple as 


it would sound, is fraught with dangerous pitfalls. One has seen a case in 
which a point a quarter of an inch above the angle of the mouth really belonged 
to the infra-orbital margin. The tissues had been stretched to this extent 
without dragging down the lower lid to any marked degree, and one might 
have been forgiven for regarding the stretched skin as part of the cheek. 

Here, as elsewhere, the aim is to estimate first the amount of loss ; and, 
secondly, the possibility of correcting displacement. 

It is often impossible to do so till one has undone some previous effort at 

A moment's consideration will show that no estimation of the loss or dis- 
tortion of soft tissues can be of use unless coupled with a knowledge of the 
condition of the bony tissue. When there is greater loss of the underlying 
mandible than of the skin, one is apt to conclude that there is no great loss 
of skin. In such a case, one must visualise a completely restored mandible, 
and then judge whether the remaining soft tissues are sufficient to cover it. 
In this connection, if a photograph is obtainable of the condition before injury 
it will often be of great assistance. In the case of any organ forming the wall 
of a mucous cavity, such as the lip, it is necessary to make an accurate estimate 
of the loss of mucous membrane. In fact, estimation of loss should be made 
separately in regard to (1) the mucous lining, (2)- the bony or cartilaginous 
support, and (3) the skin covering. The estimation of bony loss necessitates 
intranasal and intra-oral and radiographic examination in addition to surface 
palpation, and even then is often difficult to make in cases where the injury 
is symmetrical. One has seen an intrinsically well-made nose constructed upon 
a bed at least one inch posterior to the normal plane : the loss of the nasal spine 
and premaxilla had not been taken into consideration, and the face, to the 
surgeon's disappointment, presented an undershot appearance. 

To overcome such difficulties, Surgery calls Art to its aid. A^ pi aster cast 
of the face is made, and thereon the sculptor, aided by early photographs if 
available, models the missing contours. With radiographs to confirm that the 
apparent loss is not merely displacement, the surgeon now has data for adequate 


The diagnosis established and recorded, the surgeon plans his repair. The 
first principle is one which the author believes to govern the whole treatment 
of facial injuries, and this is that all jiormal jjssue_sh m ild be replaced as early 
asjjossible, and maintained in its normal position. In treating an early wound 
there is a natural disposition to try to close unsightly gaps. More harm than 


good is done thereby, as the reactionary swelling and the frequent suppuration 
cause more scar tissue than would otherwise have to be dealt with, and the 
stitches only too often give way. In addition to this undue stretching of the 
damaged tissues, the early cutting of flaps is, in the author's opinion, to be 
condemned ; for, even when this procedure is successful, no obvious gain in time 
or appearance is obtained, while considerable risk of suppuration is run. It 
follows, therefore, that split lips, lacerated noses, and gashed cheeks, where 
the loss of tissue is negligible, should be carefully sewn up with drainage as 
soon as possible. Every effort should be made to replace tissues in their normal 
position by stitches, strapping, head-gear apparatus, nasal supports and splints, 
but never into abnormal positions. There is one exception to this which de- 
serves mention, namely, that tags of mucous membrane should, faute de mieux, 
be delicately attached to any neighbouring raw surface to preserve their form 
and vitality. 

In the very common facial injury, where one of the mucous cavities is 
involved in the wound and the loss is so great that the repair cannot be done 
without undue stretching, the modern practice of excising the wound should 
be brought into play, and then the skin sewn to mucous membrane round the 
margin of the defect. This should be done wherever possible, so that as little 
raw area as possible is left to granulate. In dealing with lacerated mucous 
membrane, the greatest delicacy of touch must be used, and in effecting the 
suture as little manipulation of the tissues as possible should be indulged in. 
A corollary of this belief of the author's is that in clearly defined gaps of the 
mandible, the end of the bone should be smoothed off and the buccal mucous 
membrane sewn across the raw bone, a procedure advocated by Trotter. Were 
it possible of achievement as a routine, it would almost certainly prevent ci- 
catricial approximation of the fragments ; but one realises that, with many 
other suggestions for early treatment, it is a counsel of perfection, and, in very 
severe injuries, may well be impracticable under conditions of active warfare. 

In the early treatment of all wounds involving the oral cavity the dental 
surgeon must be encouraged to take a large share of responsibility. His treat- 
ment will begin naturally with a general nettoyage of the alveolar area. Loose 
and septic teeth and stumps must be extracted, and, as soon as can be accurately 
determined, the teeth obviously in the line of fracture (the persistence of which 
is not of vital importance for the fixation of the fragments) should be removed. 
Frequently the decision as to whether a tooth is or is not in the line of fracture 
has to be modified, and it may become necessary to remove more teeth than 
was first expected. The most careful watch for persistent pockets of pus must 
be maintained. 

In many cases it will be found of great advantage to provide infra-mandibular 


drainage on to the neck surface beneath the various lines of fracture. This 
sounds reasonable and simple, but in practice it is found quite difficult adequately 
to drain some classes of comminuted fractures, and the mandibular remains 
are apt to carry on their existence in a sump of pus (visually, one must admit, 
with considerable success !). 

For this as well as for general reasons, the passive drainage is greatly assisted 
by frequent forcible irrigation, the Carrel continuous irrigation being not always 
practicable in this region. 

By adequate drainage alone are the dangers of secondary haemorrhage 
avoided, and it is one's experience that those cases in which there is a small 
perforating wound of the body of the mandible are most prone to this disaster. 
One has never seen a serious haemorrhage in a case of facial wound in which 
the loss of bone and soft tissues is great, and it would almost seem advisable 
that these small wounds should be considerably enlarged, and skin sewn to 
mucous membrane to make these openings persist till secondary suture can 
be safely undertaken. The author does not propose to dilate upon the treatment 
of secondary haemorrhage. 

Apart from this dental toilet, the chief role of the dentist lies in controlling 
the bony fragments. The author is disappointed with the results of the so-called 
suspensory wiring of fragments, which involves the wrong principle of putting 
foreign bodies in contact with inflammatory bone lesions. The facial surgeon 
has the advantage of the orthopaedist, in that his instrument-maker is a pro- 
fessional colleague who has for his goal the provision of the best masticatory 
result. The dental surgeon must be fully alive to the possibilities of his surgeon 
and of surgery in general. Thus, in the early days of bone-grafting, many 
wide gaps of the mandible were brought together by the dental surgeon in the 
early stages in order to get bony union in a shortened mandibular arch. With 
the rapid success of mandibular grafting this procedure has become extinct, 
and it is the author's opinion that it is rarely justifiable to shorten the mandibular 
arch. The class of case where it is permissible is that in which the patient 
is edentulous, and the loss of bone minimal. 


A man with loss of the upper lip, say, arrives from France with the remains 
sutured across beneath his nose and possibly healed there. Frequently the 
first step is to reconstitute the wound by the release of the overstretched tissues. 
The mucosa of the lip stumps is then secured by suturing it to skin over the 
raw edges. This very important measure should be employed by the first 
surgeon who sees the case after injury. Only now, as a rule, is it possible really 


to diagnose the loss and plan the restoration. (Sometimes this replacement 
of the first stage of any plastic operation can be imitated by moving putty flaps 
upon the plaster cast as one would the flesh.) In planning the restoration, 
junction is the first consideration, and it is indeed fortunate that the best cos- 
metic results are, as a rule, only to be obtained where function has been restored. 
Perhaps the first question that arises in any case is the relative expediency of 
attempting surgical repair or mechanical camouflage, and a satisfactory decision 
can be arrived at only as a result of long experience. Sometimes in the end 
the repair undertaken is a compromise between surgery and mechanics, the 
decision being based on the severity and multiplicity of the operations needed 
to effect a surgical cure, and on the patient's lack of stamina ; or on factors 
outside the present discussion. One looks forward with confidence to a plastic 
millennium when, given a healthy patient and no time restrictions, it will be 
possible to cope surgically with any reasonable facial loss. 

The restoration is designed from within outwards. The lining membrane 
must be considered first, then the supporting structures, and finally the skin 

Lining Membrane. Omission to provide a lining membrane for mucous 
cavities has in the past been the supreme cause of plastic failure. Kcegan 
quotes a President of the Royal College of Surgeons in 1863, as mournfully 
describing how a well-shaped plastic nose is prone to wither away on the patient's 
face. The author has seen examples of a similar occurrence in recent times, 
for want of a lining ; and many cases of post-operative nasal stenosis, microstoma, 
and contracted eye-socket are traceable to the same cause. Even to this date 
the author has frequently to perform a second rhinoplasty upon patients who, 
during a portion of their plastic career, proudly flaunted new and shapely noses, 
which gradually diminished in size as a result of ulcerative processes within. 

Mucous membrane is not often available except in the smaller mouth 
defects, and the results of free mucosal grafts have been poor. Recourse, 
therefore, is had to skin, either in the form of flaps or grafts. In its new and 
moist condition of existence the surface epithelium appears macroscopically 
to approach the mucosal type. In the nose, the formation of the mucosal 
lining by swinging turbinatcs and septum into the desired position has been 
successfully used on a number of occasions. When not available, an epithelial 
lining is usually provided by means of cheek and bridge flaps turned skin in- 
wards. If these flaps are not available, their place is taken by a Thiersch graft. 
Similar type flaps from the margin of the defect or Thiersch grafts are used 
in the rebuilding of the ocular aspect of new eyelids. In the smaller lesions 
of the oral cavity, the new cheek or lip is lined by the advancement of mucous 
flaps from the intact portions. Mucous membrane flaps are also used to replace 


losses of the vermilion border of the lips. When sewn over the raw edge of 
the lip and thus exposed to the air, the buccal mucosa seems gradually to give 
up the power of secreting without losing its colour, and a very natural appear- 
ance is produced. In larger losses, the method of inturned skin flaps from 
the neighbourhood is resorted to. It often happens that these flaps are hair- 
bearing, a property which they retain in their new situation. The disability, 
however, is not greatly complained of, and when excessive can be over- 
come by dissecting off the hair-bearing layer later on, and Thiersch grafting. 
The author has utilised non-hairy portions of forehead or of chest flaps turned 
in as a lining for a buccal restoration. Several surgeons favour the grafting 
of a separate flap of hairless epithelium on to the under-surface of the flap designed 
to form the outside covering, before the latter is moved into position. This is 
tedious, and a similar result can be more easily arrived at by the tube-pedicle 
principle. Epilation by X-rays is unsatisfactory in the author's experience. 
There is long delay. Permanent epilation is rarely obtained, and when 
obtained the skin is avascular and atonic, and burns are liable to occur in 
the process. 

The fitting of an efficient denture upon a mandible robbed of its alveolar 
ridge usually depends on the provision of a much-deepened labiogingival sulcus 
to hold a flange of the appliance. Before the importance of lining the deepened 
sulcus had been recognised, it was found impossible to prevent its gradual 
obliteration by fibrous tissue. Now, thanks to development of the Esser inlay, 
the sulcus can be permanently deepened in one small operation. 

The Esser Epithelial Inlay. The provision of a lining for a deepened sulcus 
was first carried out by Esser (vide Annals of Surgery, March 1917). He 
inserted a moulded piece of dental composition wrapped round with a Thiersch 
graft (deep surface outwards) into a pocket dissected out subjacent to the 
mucosal lining of the existing sulcus, the whole operation being performed 
through a skin incision. After a suitable interval the bottom of the sulcus 
was incised, and the mould removed per oram, leaving the skin-lined cavity as 
an extension of the sulcus. 

The author having practised the typical Esser inlay with considerable 
success and also extended its principles to the cure of ectropic conditions, it 
occurred to his Dominion colleagues to simplify the method for providing a 
lining membrane. Having discussed with the author the possibility of intro- 
ducing the skin-graft per oram, Lieut. -Colonel C. W. Waldron, C.A.M.C., was 
the first to perform this modification in this hospital. He was closely and 
independently followed by Lieut.-Colonel H. P. Pickerill, O.B.E., N.Z.M.C. 

Its obvious success led to great activity in the sectional dental departments 
for its further improvement and simplification. 



The details of the method are as follows : 

A dental splint destined to control the Stent l is fitted to any existing teeth 
or to the alveolar ridge (see figs. 1 and 2), and the sulcus is deepened per oram 
to the satisfaction of the dental surgeon. 

In this operation all scar tissue must be excised, and the knife must be 
kept close to the bone, so that no loose soft tissues remain on the alveolar wall 
of the sulcus. 

An impression of the new sulcus is taken with warm Stent, which is made 
to distend the cavity. When set, it is adjusted to the dental splint. It is 

Fio. 1. Epithelial Inlay. (The arrows mark the limit of the skin graft.) 

then taken out and completely covered with a large, thin, evenly cut Thicrsch 
skin-graft, deep surface outward, and is pressed firmly into the rawed sulcus 
and there maintained ten days by the splint. Meanwhile the dentist prepares 
his appliance, and must be ready to fit it the moment the Stent is removed, as 
the cavity is liable to shrink if left unoccupied for any length of time. As 
an intermediary stage between the Stent and the final appliance, a mould of 
black gutta-percha is sometimes used. 

This operation may well be performed under regional anesthesia. The 

1 The dental composition used for this purpose is that put forward by Stent, and a mould composed 
of it is known us a " !Stent." 



I. The obliterated Sulcus. 

2. Incision close to the bone. 

3. Sulcus deepened. 

4. Skin graft on Stent. 

5. Graft on Stent in position. 

7. Operation completed. 

6. Cap splint with horizontal 8. Ten days later. Stent removed : Sulcus 
adjustable flange. permanently deepened and lined. 

Fio. 2. Stages in the Epithelial Inlay. 

author is of opinion that the original method of Esser, difficult as it is, is still 
the method of choice in a few rare cases. 

A similar procedure has been successfully used in the nasal cavity, and for 
lining the ocular aspect of a new eyelid. 


The principle of the Esser Inlay marks an epoch in surgery, and the oppor- 
tunities for its application are far from exhausted. A further modification 
of it is discussed in this chapter in the pages devoted to " Coverings." 

Supporting Structure. The importance of the general contour of the face 
in the matter of expression is only realised gradually. Disappointment is in 
store for him who would confine his repair to the surface tissues, heedless of 
Nature's lessons in architecture. Theoretically, the application of one's ana- 
tomical knowledge should suffice to point out the value of contour, but in 
practice the realisation comes only by close co-operation with the sculptor. 
In this matter of the general form of the part all sorts of artificial implantations 
have been tried. Metallic plates and filigrees, celluloid plates, and injections 
of liquid celluloid, solid pieces of wax, and injections of molten wax, have all 
been used to build up the missing contour. Speaking generally, the use of any 
foreign body is to be condemned whenever it is possible to substitute a graft 
from the patient himself. Any form of a foreign body is a tissue irritant, and 
tends to give trouble early qr late, in the attempt on the part of the tissues 
to remove it ; whereas grafts, if successful in the early stages, continue satis- 
factory. One celluloid plate which was used to replace a zygomatic prominence 
developed over it a cold abscess five months after its implantation. The 
healing had been primary, and when the abscess burst, the skin again healed 
over the plate. But by far the greater number of celluloid plates had to be 
removed within two months of their insertion. 

Satisfactory early results are obtained by very cautious and repeated 
injections of paraffin wax in small quantities, but the late results are rarely 
good and are often appalling. It is not. suitable for the larger restorations, 
and the imbedding of solid blocks of paraffin has not, in the author's experience, 
been tolerated. The little experience the author has had with buried metallic 
or vulcanite plates discourages further experiment with them. Professor 
Mat-Bride, of the Imperial Research Laboratory, is at present carrying out a 
research for the author on the implantation of celloidin into the ears of mice. 

There is no royal road to the fashioning of the facial scaffold by artificial 
means : the surgeon must tread the hard and narrow way of pure surgery. 
Of the various autologous grafts available one has had enough experience to 
form some conclusions. It may be laid down as a guiding maxim that the 
replacement should be as nearly as possible in terms of the tissues lost, i.e. 
bone for bone, cartilage for cartilage, fat for fat, etc. The use of bone-grafts 
has been narrowed down to the replacement of mandibular and malar losses. 

Cartilage for large cosmetic purposes stands unrivalled. It is available in 
sufficient quantity, is easily fashioned to the desired shape, and, what is most 
important, remains permanently in the shape and size in which it is imbedded, 


with the exception that if one perichondrial surface only is left, the graft tends 
to bend, the perichondrium occupying the concavity ; and this property of 
cartilage is utilised by the surgeon to obtain a curve in such positions as the 
eyelids or the mandible. In cases of suppuration, there may be necrosis of 
part of the cartilage and a corresponding secondary deformity may arise. This 
is also the case when a part of the cartilage is left exposed in a mucous cavity. 
The clinical evidence of the permanence of cartilage is borne out by the ex- 
perimental work of Staige Davis (Annals of Surgery, 1917, vol. Ixvi, p. 88), 
and by the histological work of Keith and Murray. (See figs. 3, 4, and 5, 6.) 

The method of obtaining cartilage is a modification of that suggested by 
Nelaton. A six-inch vertical incision is made over the costal cartilages having 
its middle opposite the seventh, and is deepened through the rectus muscle, 
which is widely retracted. The seventh, or the seventh and eighth cartilages, 
are dissected free and removed with perichondrium intact, and are at once 
transferred, wrapped in sterile gauze, to a table with three edges raised to prevent 
disaster during the shaping of the graft. The wound is sutured by an assistant, 
and the thorax strapped as for a fractured rib in order to avoid pain, which is 
otherwise likely to be severe. Meanwhile, the surgeon shapes his graft with 
a scalpel, leaving the perichondrium on one surface in cases where a curve or 
a spring effect is desired. The graft is put into place and the wound sutured 
without drainage, except in those cases where a lijematoma appears likely, 
and any excess of cartilage is inserted under the skin of the upper abdomen 
as a store for use in future operations, the pain of a further rib excision being 
thus avoided. This hoard of cartilage may prove of use to others if not wholly 
required by the patient himself. The question of homologous grafts opened 
up by this procedure is of extreme interest, and a definite decision as to their 
expediency has not yet been arrived at. It goes without saying that the donor 
must be proved free from syphilis. 

In this connection one had the opportunity of furnishing material from 
various autologous and homologous cartilage grafts to Professor Keith. Dr. 
J. Alexander Murray undertook this research for Professor Keith. Illustra- 
tions (figs. 3 and 5) of two of his sections are given. Captain V- - and 
Lieut. S were operated upon the same day. Some cartilage from 
Captain V- - was put into the subcutaneous abdominal tissues of both Captain 
V- - (autologous) and Lieut. S - (homologous). After eighteen months 
the opportunity arose of removing these grafts. There is no doubt that in 
both cases the cartilage is alive and active, but Dr. Murray finds that the cells 
in the homologous (Lieut. S -) are more vacuolated and show more cal- 
careous changes (i.e. degenerative) than do those of Captain V- . (See figs. 
4 and 6.) 


It should be noted that neither of these two grafts was submitted to stress 
or strain in the region where it was buried. The author hopes that when 
a cartilage graft is put under fairly normal conditions of functional existence, 
such as is obtained when it is employed in nasal reconstruction, it will persist 
in the form and position given it. Certainly, in the author's experience, no 
changes other than curvature toward the perichondrial surface have occurred 
in any of his successful autologous grafts, and in only a few of the homologous 
grafts has the cartilage become replaced by fibrous tissue as a late sequel. Three 
years is the longest that the author has had a graft under observation. Even 
if partial calcification should occur this does not depose cartilage from its place 
as facile princeps among facial supports. 

The insertion of a cartilage graft may constitute a whole operation, as, 
for instance, when it is introduced subcutaneously to elevate a depressed nasal 
bridge ; or it may form a stage in a series of operations. In rhinoplasty (author's 
method) the cartilage support for the nasal bridge is usually inserted subcu- 
taneously under the skin over the glabella the skin destined for the lining 
of the new nose and is swung down attached to the deep surface of this when 
it is turned down at a later stage. 

In the method suggested by Nelaton the support is swung down on the 
deep surface of the flap designed to form the covering of the nose, a method 
hampering free manipulation of the graft with a view to fixing it in the best 

It is sometimes convenient to employ yet a fourth method, in which the 
support is built into its final position between the lining and the covering, before 
the flap is raised. This procedure has been successfully followed in the replace- 
ment of facial losses by pedicled chest-flaps. The part is fashioned upon the 
chest by the manipulation of small skin-flaps, the cartilage graft being introduced 
between two layers of a flap doubled upon itself, or between the flap and a 
Thiersch covering of its under-surface. 

When a softer contour is desired than would be provided by cartilage, local 
fat and muscle flaps are used to fill the smaller hollows. The use of fat-flaps 
is most satisfactory, and should be employed for all depressed scars. They 
are discussed later in this chapter, and examples of their use are given in the 
section on Cheeks. For larger hollows, free fat and muscle grafts are used ; 
these are naturally more uncertain of result. All the author feels it possible 
to say of fat-grafts is, that when successful, the result is very satisfactory, arc! 
alteration of the contour from absorption has not occurred to any appreciable 
extent while the case has been under observation. It is not yet established 
lm\v they will be affected in conditions of wasting, or in old age. The fat-graft, 
however, owing to fat necrosis, often undergoes a partial absorption, which is 



FIGS. 3 and 4. V. (Autologous graft.) No reaction at cut surface. 
There is only a very shallow layer 1-2 cells deep of dead 
cartilage cells. Under the old perichondrial surface the cells have remained healthy. In the 
central parts of the cartilage the cells are arranged in small groups with deeply stained areas 
of matrix around them very much the condition seen in normal adult costal cartilage. The 
general matrix stains more faintly and is generally faintly fibrillated. This is not excessive. 


-V... v 



FIGS. 5 and 0. V. rib. cart, in S. (Homologous graft.) The 

cartilage cells are throughout more active, and occur not in -$ 

clumps, as in the donor, but in long columns towards "'*. .., ,* 

the perichondrial surface isolated cells of spindle form are 

most numerous. In the deeper parts rounded groups with 

darkly-stained secondary capsules occur also. Fibrillation of the general matrix is fairly frequent, 

but not excessive. It looks as if the graft in the strange soil had proliferated more actively, and 

was still remote from the quiescent stage which is seen in the autologous graft. 




carried to greater lengths if the products of this disintegration become infected ; 
but even in this latter unfortunate event not all the fat (or muscle) comes away, 
and eventually there is left sufficient substance to aid very materially in any 
future work on the part. Fat-grafts are frequently recommended as a pre- 
liminary to a bone-graft, and, in the author's opinion, rightly so. 

Of other ways of building up the facial contour, the author would like to 
draw attention to the following, which are available only in certain localities. 
The malar prominence may be simulated satisfactorily by the svibcutaneous 
advancement of the adjacent temporal muscle, as described on p. 55. In 
partial or complete rhinoplasty, considerable help is sometimes obtained in 
building up the sides or bridge of the nose by the use of turbinate grafts and 
muco-cartilaginous flaps from the septum, before the skin covering is applied. 

With regard to anterior palatal perforations involving loss of the premaxilla, 
it is not the author's practice to attempt a purely surgical repair. The goal 
of obtaining efficient mastication is more certainly achieved by a mechanical 
repair at the hands of the dental surgeon. 

The Covering Tissues. In the provision of a covering there is little choice 
in the way of material : one has to decide between using a skin-flap or one of 
the types of skin-graft. 

Generally speaking, the application of skin-grafts is limited to superficial 
lesions. Where a gap is to be bridged, or where tension is likely to occur, a 
skin-flap is indicated. 

Skin-grafts. The preparation and manipulation of the various forms of 
skin-grafts with a nice judgment in their use constitute an important part of 
the plastic surgeon's stock-in-trade. 

(1) Thiersch grafts. In plastic work the simple Thiersch graft is not of 
very wide application, but in specialised forms its use covers a very wide range. 
The Esser Inlay has been already fully described. The author has adapted 
the Esser inlay to surface use in the method known as the " Epithelial Outlay," 
which finds its most important application in his operation for the relief of 
ectropion of the lids, as follows : An incision is made, skirting the lid edge, 
and the lid liberated by dissecting freely till closure can be effected without 
tension. In the resulting cavity is buried a closely fitting Stent mould covered 
with a Thiersch graft, over which the edges of the incision are sewn with horse- 
hair, the sutures taking up the edges of the skin-graft. After some eight days 
the Stent either falls out or is removed, and the lid falls easily into position. 
See section on Burns, pp. 376-7, and fig. 7. 

The principle is applicable in many other localities, notably in cases of 
adhesions between the pinna and the scalp following burns. 

(2) H'olje and W hole-thickness gmJts.~T\\e factors determining the successful 



use of these grafts are somewhat obscure, but it may be laid down that firm 
apposition and accurate coaptation of the edges are essential. It would seem 
also that tension assists tension of a degree comparable with that obtaining 
in the area from which the graft is taken. Apposition is most easily achieved 
and maintained when bone or cartilage closely underlies the area to be covered, 






FIG. 7. Stages in the Epithelial Outlay Operation. 

as in the forehead or nose ; and it is only in such regions that immobility 
obviously a desirable factor is obtainable. 

The fact that a large graft is less likely to take in its entirety than is a 
small one is improbably due to any inherent disability in the question of size ; 
it is very possibly explained by the fact that the above-mentioned factors are 
more difficult of attainment in a large graft. 



These grafts are in routine use for covering raw areas upon the forehead 
left by the removal of rhinoplastic flaps, and for providing a healthy covering 
for the nose in cases of severe facial burns. For small areas the skin may be 
taken from the back of the neck ; for areas up to two inches in diameter the 
skin is taken from over the biceps the conditions of tension in this region 
being suitable. Larger grafts are taken from the chest or abdomen. 

The question as to whether the graft shall be skin-deep or contain a layer 
of fat is determined by the needs of the case, there being no marked disparity 
between the two in the matter of viability. If hair is required the scalp in 
the post-auricular region is employed ; the author has successfully used whole- 
thickness grafts from this region in the replacement of eyebrows lost through 
burns. (Case No. 338, p. 356.) The details of the method employed in a typical 
case may be of interest ; the example taken is the grafting of the raw area on 
the forehead after a rhinoplasty, where the returned pedicle is inadequate wholly 
to cover the defect. 

By the time the pedicle is returned the area is covered by healthy granu- 
lations. It is customary to scrape these away, as in cases where they have 
been left the patients have complained of a feeling of constriction round the 
head, presumably caused by the contraction of this large mass of scar tissue. 
The area to be covered is accurately mapped out with tinfoil, and the foil outlined 
upon the chest or upper arm with the point of the knife. The graft is then 
dissected up, care being exercised to avoid bruising it with forceps. It shrinks 
greatly as it is freed. If the bone is exposed on the forehead, the graft is cut 
so as to contain a layer of fat, for though a graft will often take upon bare bone 
it is liable to adhere too closely for normal movement unless fat intervenes. 
Fixation sutures are now inserted at the corners of the graft, so as to ensure 
symmetrical tension, and accurate coaptation of the edges is then effected with 
continuous horsehair sutures. Meanwhile, an assistant has prepared a Stent- 
backing to the tinfoil map of the area, and this is firmly pressed into the 
slight depression now occupied by the graft while still in a semi-solid condition, 
and the whole firmly bandaged to the head. The pressure is maintained for 
about forty-eight hours, and the graft then observed. If the prognosis is 
favourable, it will by this time have assumed a somewhat forbidding livid and 
mottled appearance, and will have swelled considerably. Any portions that 
have died will appear white and opaque, or black (underiun by clot). Stitches 
are removed about the fifth day, and massage is applied after about three weeks. 

Skin-flaps. The delineation and manipulation of skin-flaps constitute 
the ABC of the plastic surgeon's metier. The subject has been worn threadbare 
in countless textbooks, and it is not proposed here to give a compendium of all 
possible flaps. 



Essentially, all flaps are similar, and consist of two parts the part chiefly 
concerned with the traffic in circulatory fluids, and the part available for plastic 

Broadly speaking, flaps may be grouped as follows : 

A. Advancing flaps. 

B. Transposed flaps. 

The differences are portrayed in the following diagrams illustrating their 
use, the pages devoted thereto being intended as part of a glossary for terms 
used later in the book. 

The majority of the terms used are self-explanatory. " Ascending " 
flaps are those in which the skin from below the defect is swung up on a base 
roughly on the same level as the defect. Thus, an " ascending neck-flap " is 
one the body of which has been raised from the neck, the base being, for instance, 
on the lateral aspect of the chin. 

In actual use, modifications of these flaps are employed according to the 
locality ; thus, for rhinoplasty, instead of the traditional forehead bridge flap, 
the author is now employing a long flap containing the anterior branch of the 
superficial temporal artery, based on the pre-auricular region. The middle 
portion of the flap is " tubed " (see figs. p. 21), and when severed from the plastic 
portion after some ten days, is opened out and replaced upon the forehead, 
leaving a raw area no larger than that left by the Indian method. The blood- 
supply of this flap is remarkable ; its nourishing vessel spouts freely when the 
tubed portion is severed from the new nose. 

The transposed flap (imbedded type) is usually employed about the eyes 
and mouth, a depression of the buccal orifice being relieved by transposing a 
flap from the corresponding naso-labial fold to a position below the orifice, the 
flap in this case being a " descending naso-labial flap." If the tissue in the 
naso-labial fold is scarred or otherwise unsuitable, an ascending neck-flap can be 
employed to produce, in a less degree, a similar result. But in this case the 
flap must be taken from the side of the neck, being swung through ninety degrees 
from a vertical to a horizontal position ; otherwise the gain of skin below the 

Fio. 8. Flaps. 
1. SIMPLE ADVANCEMENT (Forward type). 


Incisions and Excision. 

Flap A. Advancing. 



2. " V. Y. 1 ' ADVANCEMENT. 



Defect. Incision. Suture. 

3. SWINGING ADVANCEMENT (Combination of Forward and Lateral Advancement). 








(a) Si m pl e Pedicle. 


""^ A 


Eyebrows lacking. 




(6) With Pedicle "tubed." (Author's Method.) 

^ L 



Flap Pedicle " tubed." 

Flap swinging upon Pedicle. 


Pedicle being returned and unrolled. 


mouth has to be written off against the loss which occurs when the bed from 
which it was raised is closed. 

The use of flaps is not confined wholly to the provision of a skin covering. 
In many cases the flap is used as a vehicle for the introduction of a cartilaginous 
support previously imbedded in it, as discussed earlier in this chapter. A 
typical example occurs in the reconstruction of the nose, in which the bridge 
support a cartilage rod is imbedded under the skin destined to form the 
lining of the vestibule, and swung down upon its deep surface to occupy a position 
between the lining and the covering. (Figs. 388 and 389.) A similar principle 
has been employed in the reconstruction of the chin in a chest-flap previous 
to its elevation. 

The plastic surgeon must early acquire an instinct for forecasting the 
viability of the flaps he uses. Apart from those containing a definite artery 
such as the superficial temporal (the base for which may be cut quite narrow), 
generally speaking the base should be at least as wide as any other part of the 
flap. The length which may be safely taken varies with the breadth and depth 
-particularly the depth. If the depth includes no more than the true skin, it 
seems in practice safer to use a graft than a flap : a skin-deep flap of any length 
is found rapidly to become cedematous, and often dies from the obstruction 
thus caused. The explanation perhaps lies in the fact that egress for the products 
of metabolism is inadequate. In the early stages of a free graft the ebb and 
the flow of tissue-fluids are conditioned by the same factor, the osmosis resulting 
from the biochemical activity of the cells : the matter is not complicated by 
the continued arrival of fluid from without, and marked congestion does not 

In the event of oedema of an intensity likely to jeopardise the life of the 
flap, it has been taught that multiple punctures are indicated. The author 
prefers gentle efferent massage, which avoids the creation of minute thrombi 
and of extra channels of infection, and which helps to dissipate the commencing 
lymphatic and venous stasis. Furthermore, hot moist dressings have a definite 
effect in helping the sluggish corpuscle back to the normal circulation. It is 
the author's opinion that in a flap thrombosis may be caused by merely a few 
minutes' pressure, as from a kink. 

The viability of flaps varies greatly in different regions. Those based 
about the chin are never a cause of anxiety, whereas ascending flaps from the 
neck contain the possibilities of disaster and must be treated with the greatest 
respect. It is of advantage, when dealing with a flap whose chances of life are 
precarious, to wrap it with a hot saline pad during the ligature of arteries, etc. 
It goes without saying that in cutting a flap one should, if possible, avoid its 
containing scar tissue : in the altered condition of existence the scar is liable 


to swell, not only forming ah unsightly blemish but being highly prejudicial 
to the blood supply. 

Among other conditions which are prone to affect the viability of a flap, 
the surface to which it is applied exercises a most powerful influence. It has 
been observed that flaps containing scar tissue which would certainly die if im- 
planted upon the face, will often live upon the same base if applied to form the 
lining of a mucous cavity, where warmth and moisture are present. 

In this question of viability of flaps the personal equation of the patient 
and of the surgeon comes strongly to the fore. 


The administration of anaesthetics for the plastic surgeon is a highly special- 
ised procedure. 

To begin with, the majority of plastic operations are unavoidably long ; 

tthe insertion of sutures alone is apt to occupy a skilled surgeon more than half 
an hour. The type of patient, too, is often unfavourable, especially in cases 
of wounds involving the oral cavity, where a long convalescence has been 
hampered by ill nourishment. 

Moreover, the airway, in many cases, is strangely distorted in some part 
of its course ; and, in addition, the surgeon must perforce trespass upon the 
territory usually regarded by the anaesthetist as his own. 

Evidently, therefore, there is scope for any and every device that will 
diminish effort for the patient and the anaesthetist, and bring the prolonged 
strain within the limits of endurance. 

An arrangement must be come to also by which the surgeon is spared the 
disability of disputing the possession of the parts. 

For large operations upon the mouth region, intra-tracheal administration 
in some form has been adopted as a routine. Where the form of the parts 
permits, a catheter is introduced into the trachea through a Mosher's laryngeal 
speculum under the guidance of vision. This may be prevented by the pro- 
jection of splints fitted to the upper jaw, or by conditions of microstoma, trismus, 
contracted mandibular arch, etc., in which case intra-tracheal anaesthesia is 
effected by means of a laryngotomy, or, in rare instances, a tracheotomy. Ether 
t is the intra-tracheal anaesthetic of choice. It is given under positive pressure, 
being carried either by a stream of oxygen from a large cylinder or by a stream 
of air propelled by a small electrically driven motor, either way leaving the 
anaesthetist the use of both his hands for the manipulation of the stop-cocks, etc. 

In smaller operations upon the mouth, it is found convenient to use a nasal 


tube or tubes, the pharynx being shut off by plugging the hinder portion of the 
buccal cavity with loose gauze which is renewed from time to time. 

When the operation is upon the nose, the nose and post-nasal space are 
plugged, and a Hewitt's airway is employed. 

In all these cases, the anaesthetic is conveyed through a tube long enough 
to avoid interference with the surgeon, the means of propulsion being as in 
the intra-tracheal method. 

Administration by positive pressure undoubtedly relieves the patient of 
much of the strain of a long operation, and the ease with which pure oxygen 
or air can be substituted for anaesthetic through the clear airway achieved by 
the methods described, diminishes the stress associated with cyanosis to a 
minimum. The difficulties consequent upon the routine adoption of these 
methods are easily overcome with practice. The anaesthetist must learn to 
depend almost solely on the respiratory movements and the pulse as his guide, 
with rare peeps at the pupil. 

I propose here to discuss some of our methods in more detail : 

Chloroform and Oxygen in the Sitting-up Position. This method was intro- 
duced to us by Colonel J. F. W. Silk, Consultant Anaesthetist to the War Office, 
in September 1916. It is most suitable for upper lip operations with or 
without loss of continuity in the maxilla. It is also useful for those cases 
of extensive loss in the mandible where the fragments cannot be held by 
suitable splints. The advantages of the method are, firstly, that the blood 
flows forward out of the mouth ; secondly, there is less bleeding ; thirdly, the 
surgeon has a very good view of the patient's face. But it is certainly a tiring 
position in which to operate. 

In my experience, with healthy men it is a safe form of anaesthesia. In 
200 cases I have never had to alter the position during the early stages. Very 
occasionally they become faint towards the end of long operations and have 
to be lowered to the horizontal, where they quickly recover. A very light anaes- 
thesia is required after the first half-hour. In some cases they pass into a stage 
of analgesia, during which they will answer remarks quite sensibly for half an 
hour or more before the operation is finished. 

Technique. One end of the operating-table must be capable of being raised 
to the perpendicular, and must be long enough to reach to the patient's shoulders 
in this position. A suitable head-rest must also be attached. Induction is 
carried out in the sitting position, the back of the table being raised to just 
short of the perpendicular. When induction is completed the head is bound 
firmly to the head-rest. The position of the head is important ; if it leans too 
far back blood will flow into the fauces, if too far forward the airway may be 
obstructed. It is sometimes easier to get the best position by adjusting the 


trunk to the head. When this is satisfactory, and the patient is breathing easily, 
a No. 10 rubber catheter is passed down one nostril to the pharynx. The 
catheter is connected by a suitable length of rubber tubing to a Shipway's warm 
ether and chloroform apparatus, to which an oxygen cylinder has been attached, 
and the oxygen made to pass through the chloroform bottle at the required 
rate. The oxygen should always be turned on before the rubber tube from 
the catheter is connected to the apparatus. As a rule, this is a very convenient 
method for the anaesthetist, but occasionally the jaw requires support. If 
anaesthesia becomes deeper than the operation requires, the oxygen rate can 
be slowed or the rubber tube from the catheter disconnected from the apparatus 
for a time, or connected direct to the oxygen if necessary. 

The Nasal Tube. This was described by my colleague, Captain J. C. Clayton, 
in the Lancet. 

I always use the largest tube (size 20) which it is possible to pass down a 
nostril. If the tube is cut to a blunt point it will be found to pass more easily. 
If there is difficulty in passing one of the required size, it is better to pass a 
smaller one first, leave it in place a few seconds, and then try the larger one 
again ; in most cases this can now be passed easily. 

One of the objections to this method is that the tube is liable to kink at 
the level of the ala. I have overcome this by cutting the nasal tube short at 
the ala, and inserting into it one end of a right-angled metal connection of the 
same bore as the tube. The other end of the metal connection is joined directly 
to the funnel-end of a Kahn's tube by a short length of rubber tubing. 

This arrangement has two advantages : firstly, it provides a shorter length 
of tubing for the patient to breathe through ; and, secondly, the Kahn's tube, 
being metal, cannot be inadvertently compressed by the surgeon, and thus 
a clear airway is assured, always provided that the end of the tube is in its 
proper place just above the epiglottis and that the tube is not flattened too 
much in its passage through the nose. 

The mouth and pharynx are then loosely packed with gauze so as not to 
compress the tube. The operation should not be commenced till the patient 
is breathing comfortably. Anaesthesia can be maintained, either by dropping 
chloroform on to a layer of house-flannel stretched over the funnel, or by blowing 
a warm ether or chloroform and ether into the funnel from a Shipway apparatus. 

In some cases where the airway is just not sufficient there may be some 
cyanosis. This can be corrected by giving oxygen when necessary. It is very 
often necessary to support the jaw. 

This method is very useful for lip plastics, provided that the tube is not 
in the surgeon's way ; and for epithelial inlays and cleft palate operations. 

In the last-named I prefer to give chloroform or chloroform and ether 


from a Shipway apparatus, through a catheter passed down the nose to the 
pharynx. The patient's shoulders are raised and the head fully extended. In 
this position it is impossible for the blood to enter the larynx. The difficulty 
is to keep the patient from coughing. This can be avoided by resting the little 
finger of the hand holding up the jaw on the larynx when any swallowing move- 
ment the prelude to a cough is at once appreciated. 

The choice between this and the sitting-up position, provided the patient 
is healthy, rests entirely with the surgeon. 

In operations for reconstructing the chin or lower lip, where there is ex- 
tensive loss of the mandible and the fragments are not controlled by splints, 
there is no support for the base of the tongue, and it is very difficult to maintain 
a clear airway. Laryngotomy or tracheotomy is the simplest way out of the 
difficulty, but there are two possible objections to employing either. The 
patient will probably require more than one operation or the surgeon may 
wish to take a flap from the neck. I have only employed laryngotomy once 
in these cases, and have found one or other of the following methods satisfactory. 

(1) Chloroform and oxygen, in the sitting-up position, with the head 
slightly extended. 

(2) Kahn's tube. At one time this was used very frequently, but we gave 
it up because of the difficulty of being certain whether it was in the larynx or 
not. The following two cases were very interesting with regard to this 
point : 

The first was a bone-graft where the jaws could not be splinted. I had 
a great deal of trouble with the airway, and as a last resort introduced a Kahn's 
tube. The head was lying on the left side and covered up with towels. It 
was most unlikely that the tube entered the larynx, but the patient at once 
breathed perfectly easily through it. 

The second was a chin plastic. After a perfectly quiet anaesthetic through 
the Kahn's tube, the patient vomited at the end of the operation before the 
tube had been removed, and he vomited entirely through the tube, nothing 
coming into his mouth past it. 

If the tube is in the larynx the anaesthesia is very good indeed, and in 
these cases it is often possible to reach the larynx with the finger and be certain 
that it is in position. If it is not in the larynx, it may still be serviceable, but 
there may be trouble during the operation. I have never seen shock during 
or following its use, even in operations lasting as long as four hours. 

(3) A good airway may also be obtained by placing a small pillow under 
the patient's shoulders, extending the head, and at the same time making traction 
on the tongue. 

Chloroform and oxygen can be supplied through a catheter passed down 


the nose. If the surgeon objects to the tongue being drawn out it can be levered 
forward by a sponge-holder, the upper teeth being used as the fulcrum. 

Operations on the Nose. For short operations (under two hours) anaesthesia 
may be maintained as follows : 

After induction a silk stitch is passed through the tongue and a post-nasal 
plug introduced if necessary. A very convenient retractor for the soft palate 
can be formed by obtaining an ordinary copper retractor half an inch wide, 
and bending the last inch to a right angle. This can easily be slipped behind 
the palate, and takes up much less room than the finger. The swab is then 
introduced digitally, or with Luc's forceps. A Hewitt's airway is placed in 
the mouth ; the end of a short and suitably bent metal tube, about | in. in 
diameter, is placed just inside the mouth of the Hewitt's airway, and the other 
end connected by a rubber tube to a Shipway's warm ether apparatus. It 
must be remembered that this tube must not be too long or the vapour will 
have cooled by the time it reaches the patient. This apparatus is very econo- 
mical, and has the additional advantage of enabling the anaesthetist to maintain 
a very uniform anaesthesia. I have found that, using a mixture of chloroform 
and ether, one compression of the bulb to every third inspiration is sufficient 
to keep the majority of these men under. 

If a constant stream of air or oxygen is passed through the apparatus 
there is loss of heat and waste of anaesthetic during expiration. 

In long operations (over two hours), such as rhinoplasty, including, as a 
rule, the removal of a piece of costal cartilage, we were at one time accustomed 
to employ oil-ether anaesthesia, because of the lower incidence of post-anaesthetic 
vomiting with this method. This is especially important in rib cases on account 
of the pain. 

In properly selected cases this is a very uniform and safe anaesthesia. During 
a personal experience of over 200 cases I have only been unduly anxious about 
one patient during the operation, and that was before I gave up using hyoscine 
in the preliminary hypodermic. This method should never be used if blood 
is likely to enter the air-passages, for bleeding may continue after the patient 
leaves the theatre, and, as they usually take a long time to come round, there 
is grave risk of blood entering the trachea. 

It should not be employed if there is an obstructed airway e.g. loss in 
lower jaw without fixation, unless the anaesthetist is prepared to stay with the 
patient from the time the oil-ether is run into the rectum until the patient is 
thoroughly round from the anaesthetic. Complete rhinoplasty involves little risk 
of post-operative bleeding, and I have rarely seen any trouble in these cases. 

The post-nasal plug, if required for the operation, should be left in situ 
until the patient has recovered from the anaesthetic. 


I prefer the paraldehyde mixture ; ether 5 oz., paraldehyde 2 drams, olive 
oil 2 oz., but the paraldehyde causes excessive sweating in some patients. Dose : 
It is difficult to form any fixed plan. Some men go under quite quickly, whereas 
others of the same weight require a great deal more anaesthetic for induction. 
We have been very much handicapped by being unable to obtain olive-oil, 
and the results have been much more uniform since it has been on the market 

In cases in which blood is not likely to enter the airway (except in cases 
where the jaws are splinted together), anaesthesia may be maintained by means 
of a Shipway's warm ether apparatus, with a Hewitt's airway in the mouth, as 
described above under " Short Nose Operations." 

Bone-grafts of the Mandible. As the jaws are splinted in the closed-bite 
position intra-tracheal administration is out of the question. 

For a long time we gave oil-ether anaesthesia for these, with good results. 
The tongue is held forward by the splinted lower jaw and does not fall back. 
It is better to ensure free nose breathing by introducing a nasal tube Additional 
anaesthesia may be given either through this or through a bent metal tube placed 
in the mouth. As an alternative, a general anaesthetic may be given through 
a nasal tube as described above, under " Operations involving the Mouth." 
During the last six months we have given up oil-ether anaesthesia for these cases 
and have employed chloroform and oxygen through a nasal tube with satisfactory 
results, and I think it is to be preferred, both on account of the lessened risk 
of pneumonia, and the quick recovery from the anaesthetic. 

In this class of surgery there should be more than usual co-operation between 
the surgeon and the anaesthetist, both in regard to watchfulness over the patient's 
condition and in manipulations involving the airway. 



The general technique of a plastic operation differs slightly from that used 
in general surgery, in that the question of the ultimate appearance of the area 
of operation occupies a much more important place. The slightest insult to 
the skin of the face is in some subjects visibly recorded in scar tissue, especially 
where the blood-supply is poor from any reason, such as tension or the presence 
of scar tissue ; and it is therefore bad practice to use tissue forceps upon the 
skin edges, the grip being properly taken on the deep surface. The production 
of an invisible scar is a question constantly exercising the mind of the plastic 

A few points are given below descriptive of the author's usual practice 
with regard to general technique which may prove of interest. 


The skin of the patient is usually prepared at the time of operation by firm 
wiping of the parts with an ether swab. This removes saprophytes on the surface 
without damaging the epithelium. This is usually followed by a light coating 
of iodine, applied once only. In cases where the epithelium is tender, as in 
burnt cases, the ether is followed by methylated spirit, the iodine being omitted. 
It is also possible that iodine is an unsuitable preparation for skins that have 
previously been the seat of erysipelas. Similarly, in young subjects and in 
women where the epithelium is delicate, the iodine is omitted. The same 
holds good in the preparation of areas from which skin-grafts, either Thiersch 
or Wolfe, are to be removed. For Thiersch grafts, very vigorous rubbing with 
ether is practised until the whole area glows. 

The general care of the patient with regard to fatigue, shock, and haemorrhage 
must be borne in mind, just as in other branches of surgery. The treatment, 
actual and preventive, has no features peculiar to this branch of surgery. A 
special note of warning, however, will not be out of place in regard to the in- 
halation of blood and mucus, which will further decrease an airway often already 
insufficient, and will greatly add to the patient's fatigue in these lengthy opera- 
tions. The amount of shock produced by an operation depends, among other 
things, upon the area of disturbed skin surface. This is particularly noticeable 
when large chest skin-flaps are used for the face. 

Needless to say, the general and local condition must be the best possible 
before a major plastic operation can be undertaken. The original wound 
must have healed soundly, the condition of the upper respiratory passages and 
accessory sinuses must be above suspicion, and the skin must be free from pimples, 
acne pustules, and the like. In many cases certain preliminaries will have been 
completed, such as the excision of exuberant scars, or non-operative treatment 
to soften keloidal tissue and improve the blood-supply. 

Stages. Most of our operations consist of two or more stages. The use 
of bridge-flaps necessitates a second operation for the return of the pedicle, 
but this does not always need a general anaesthetic. The pedicle is returned 
not earlier than ten days in most cases, and it is of advantage largely to increase 
this interval where the blood-supply of the receiving bed is dubious. The 
returned pedicle covers most of the bare area from which the flap was taken, 
and the remainder is covered either by undercutting and advancing the margins, 
or by a Wolfe or whole-thickness graft. The graft, after being sutured, should 
be pressed firmly into place and held there by a pad of gauze or a Stent mould 
firmly bandaged to the head. The most frequent cause of failure of a Wolfe 
graft is lack of pressure firm enough to ensure complete apposition. Apart 
from the return of pedicles, our operations are frequently designed in stages ; 
for instance, in rhinoplasty the normal portions of the tip and alse have frequently 


to be released from scar tissue and restored to their normal positions at a stage 
prior to the remaking. At this stage also the blood-supply of the prospective 
inturned flaps is secured by attaching their future base to the rich blood-supply 
of the nasal mucosa. Similarly, in large facial replacements for burns, the 
blood-supply of the flaps is rendered more secure by the preliminary tubing 
of the pedicles. Countless other examples of the necessity of dividing the 
restoration into stages will spring to the mind of the reader. 

The simplest operation in plastic work is the excision of scars. This is 
important, not only from the cosmetic point of view. Apart from actual loss, 

1. Depressed scar. 

2. Incisions for excision of scar 
and delimitation of fat flap. 

3. Fat flap swinging. 4. Flap fixed under new scar. 


JL 1 


1. Depressed scar. 2. Incisions. 3. Suture. 

FlO. 9. Showing use of subcutaneous fat flaps. (Sectional view.) 

no factor so impedes function as does scar tissue, whether by hampering mobility 
or by constriction of tubular organs, such as blood vessels and ducts. 
The general aims in scar excision are : 

1. Liberation of fettered tissue. 

2. Restoration of contour. 

In either case it is essential that all the scar be excised. It is remarkable 
to what extent a deformity will recur if only a small amount of scar escapes. 

In unfavourable subjects it may be that the scar must be excised a second 
or even a third time before a presentable appearance is effected. 

The restoration of contour is aided by the subcutaneous rolling in of fat- 
flaps, as indicated in the accompanying diagrams. In most cases the flap is 



based on the deep fascia (fig. 9 A : 1 to 4), the skin being undercut till the desired 
area of fat is exposed, after which the knife is carried deeper till the flap can be 
drawn across and sutured in its new position. In another method (Aymard) 
the flap is based upon the overlying skin. This is more difficult of execution, 
as the knife is invisible during the delimitation of the flap, but it is the method 
of choice on occasion, especially in the malar region. 

Suture. The insertion of sutures occupies about half the time taken by 
one of these long operations. Sewing up after a total rhinoplasty takes almost .1, 
one hour even in experienced hands : so that dexterity and smooth technique 9 

Fio. 10. Author's instrument. 

in this particular are of outstanding importance for the sake of the patient. 
The " No Touch " technique is fortunately compatible with this desideratum ; 
it is found that, with practice, stitches can be tied very rapidly with forceps, 
especially with the author's instrument depicted above. This instrument also 
embodies the property of scissors, and further saves time by allowing the surgeon 
to cut his own sutures. 

The material usually employed for the apposing layer is horsehair ; its 
elasticity is of great importance in allowing a nice adjustment of the edges, 



especially when employed in continuous suture, as is very often the case. In- 
terrupted sutures are first inserted at corners and other guiding points, and the 
continuous suture is carried right past them. A trial is now being made of 
" Japanese Silkworm Gut," a material of great elasticity, the strength of which, 
in proportion to its calibre, is even greater than that of horsehair. Retaining 
sutures are of silkworm gut. 

The use of subcuticular sutures for the closure of facial wounds would at 
first sight seem to be ideal ; and, under certain conditions, this is the case. A 
long, straight incision, all portions of which are in the same plane, is best closed 
by this means. But where an incision is irregular or passes over an alteration 
of contour, the avoidance of " bunching " is so difficult with a subcuticular 
suture that a good scar is more likely to result by other means. 

Subcutaneous sutures are of great value as retaining sutures. The author 
uses a modification of the " near-far far-near " suture to subserve the double 
purpose of retention and apposition as indicated in fig. 11, which prevents in- 
version of the edges. 



FIG. 11. Subcutaneous near-far far-near suture. 

The material employed for subcuticular apposing sutures is usually horse- 
hair. Catgut is found to produce a heaped-up edge, and linen thread has, on 
more than one occasion, proved itself to be an irritant. 

Catgut is the material of choice for subcutaneous retention sutures, chromic 
gut not being well tolerated in the face. 

Invisible Scars. The author has devoted much time and thought to the 


production of the optimum scar. It actually happens on occasion that a facial 
scar is for practical purposes invisible, but one must admit that the factors for 
ensuring such a desirable result are not always to hand. 

The factors necessary for the production of the optimum scar are : 

(1) Asepsis. 

(2) Avoidance of tension on the apposing sutures. 

(3) Perfect apposition of the skin edges. 

(4) An often unknown personal factor in the patient. 

(5) Early removal of sutures. 

The avoidance of tension on the edges is found to be a factor of extreme 
importance : one often sees a transposed flap, the scar delimiting one edge of 
Avhich is clearly visible, while that along the other edge is almost invisible, the 
difference being due to the fact that there is inevitably more tension on the edge 
along the long or convex side. To avoid tension on the edges it is customary 
to insert deep retaining sutures wide of the incision, the ends being, if necessary, 
guarded by buttons to distribute the pressure. The apposing sutures should 
be inserted very close to the edges, and may be at very close interval if that 
is thought necessary to ensure a critical closure. Apposition is occasionally 
assisted by the insertion of a few everting mattress sutures about 3 mm. from 
the edge. With a view to ultimate invisibility of scar some surgeons make 
their incisions with the plane of the blade at an oblique angle with the surface, 
so that Avhen the wound is closed there is a slight overlapping of one edge by 
the other. 



FIG. 12. Incisions. 

The author has not found that this method on the whole leads to a more 
perfect scar. 

It is found that invisible scars more often occur in patients whose skins 
are ruddy and beset with small venules. Skin-flaps on such subjects are wont 
to acquire a florid habit, and their edges soon fade into their surroundings, the 
scars becoming permeated with the tiny vessels. 

Dressings. Dressings are but seldom required upon the face. Where a 



wound has been closed with drainage an appropriate covering is naturally applied, 
and it is customary in the case of grafts to provide some means of maintaining 
firm apposition ; but for the most part the face is left exposed to the air. Where 
it has been necessary to use a flap of precarious viability, hot saline packs are 
applied at the close of the operation and are renewed two-hourly, with excellent 


Apposing sutures are removed on the third or fourth day, retaining sutures 
being left till their function is fulfilled. Thus, it is the author's custom at the 
conclusion of a rhinoplasty, to insert one or more horsehair stitches transversely 
through the new nose, and tie them so as to produce a narrowing of the organ 
at certain spots. These are left till they have caused a certain amount of in- 
flammation, so that the scar-tissue which ensues will take over their function 

Massage is of great use in dispersing the oedema which often arises as a 
temporary disability in newly made flaps, and is indicated as a routine measure 
for assisting in the restoration of function. 

The closest watch is maintained during the first forty-eight hours upon the 
site of operation, especially where a new or doubtful flap has been employed. 
Even in well-tried flaps cedema may occur, and lead to disaster unless promptly 
dealt with. 

Electrical treatment in the form of vibro-massage for bone lesions, diathermy, 
ionisation, X and other rays, is part of the routine after-treatment, as in other 
branches of restorative surgery. 

A trial is being made at present of the application of a rhythmic sinusoidal 
current as an aid to osteogenesis in mandibular bone-grafts. (Barclay.) 

Early active movements are encouraged, generally speaking ; and this 
principle is applied to mandibular bone grafts where the gap is inconsiderable. 

In conclusion, it may be said that Time is the plastic surgeon's greatest 
ally, and at the same time his most trenchant critic. 



IN discussing in detail the experience in the repair of the various sections, 
it is not possible to confine each case and its method of repair within 
exact categories ; but as far as possible I have divided the face into regions, 
and each region into groups, as judged by the extent of the destruction. In 
each group the methods of repair used are set forth and the results criticised, 
while examples of cases and methods are interspersed in the reading matter, 
so that reasons for many statements may be supported by illustrations of 
actual cases. Many of these cheek injuries secondarily involve the lower eyelid, 
the nose, or the mouth ; but the following cases, though thus complicated, have 
their main interest centred in the cheek repair. Owing, however, to the obvious 
overlapping of the injury from one to other regions, cross references will fre- 
quently be made to the part of the book where the illustration is to be found. 
Thus, Case 70, in the chapter on noses, shows a very severe cheek injury, but 
as the interest of the repair, to my mind, is centred in the smaller nasal part 
of the injury, it is not separately described in the present chapter. 

The cheek is an area of plastic surgery which lends itself to good results. 
The lining membrane is not usually a stumbling-block, as in lip and nose work. 
The supporting structure, when not supplied by a dental prosthesis, is found in 
a bone graft for the mandible, cartilage for the superior maxilla, and muscle or 
cartilage for the malar-zygomatic prominence. The skin covering, when not 
available locally, is made good by flaps from the whole neck area or from the 
temporal region. 

I have arbitrarily divided this region into : 

(a) Depressed scars. 
(6) Loss of soft tissues only. 

(c) Loss of soft tissues with loss of bony substructure which may 
be deficient in the following situations : 

(1) Malar Prominence. 

(2) Superior Maxilla Alveolus, Antral Wall, Infra-orbital 


(3) Mandible. 


Depressed scars may be defined as those associated with such small losses 
of tissue that the majority of them may be repaired by excision of the scar, 
under-cutting the skin and approximation, without the necessity of cutting 



They are usually the result of the exit of a bullet, of the glancing blow of 
a fragment, or of the entrance of a small shell or bomb fragment. The scar 
produced by an exit wound is stellate, while that of an entrance wound, 
though it may be irregular, is usually concentrated in the middle of the 
depression. Of the two kinds, the radiating scar is the more difficult of 
elimination. My usual practice carries me into a somewhat tedious individual 
excision of each scar in addition to the central core. Frequently, however, a 
compromise is carried out by the removal of the more important of the 
radiations, leaving the lesser to time and the end of the war: a method 
which hastens the man's return to duty and conserves the energies and time 
of the theatre staff for more important work. Not only the scar but the 
depression should be removed, and for this purpose it is of great advantage 
to roll in local fat and muscle flaps from the surrounding area under the new 
line of union, a practice which I have carried out from the beginning, and 
which is described in detail in Principles. 

Apart from the filling of the depressions, which is the most essential part 
of the treatment of these scars, the success of the procedure is to be judged 
by the character and amount of the residual operation scar. 

If a happy result is desired, considerable thought and care must be bestowed 
on the details of the skin closure. The incision must be clear of the cicatrix, 
not only of the visible but also of the palpable portion. Horsehair, fine and 
elastic strands being chosen, gives the best result, as no other suture material 
presents this elasticity. Stitch-marks are avoided by taking out the stitches 
on the second, third, or fourth day, according to the tension, and by taking up 
the tension by deep catgut sutures. If eversion of both edges is required a 
mattress suture is employed, if of one edge only, the semi-subcuticular mattress, 
while between these everting sutures the simple or the four- twist knot is indicated. 
The various little flaps should be brought together and deep catgut inserted, 
so that there be no tension on the horsehair edge-to-edge sutures. Frequently 
difficulties arise at this stage, and one is confronted with the necessity to make 
a decision as to whether the parts can be pulled together without undue strain, 
or whether a flap is necessary to complete. It is usually easy to make, by 
further incision, one of the little flaps into a bigger one, and so overcome the 
difficulty ; and I feel that a guiding principle which stands the tests in most 
cases is that " when in doubt, cut a small flap." The fine edge sutures 
should receive minute attention, so that the very edges of the cut skin are 
apposed. Round the centre of the depression, where the apices of the stellate 
flaps meet, suturing becomes difficult. Frequently it is better to put in a 
modified purse-string or a mattress method involving more than one flap, as 
there is no room for many fine stitches. 



FIG. 13. A few days subsequent to a double shell- 

Fio. 14. After the plastic on the cheek and simple 
healing of the chin. Note the restoration of cheek 
contour, but the indifferent operation scar. 

CASE 83 

Illustrated in the accompanying figs., requires little elaboration. He was wounded 
by shell, on 23.7.16, in two separate places, each wound being of an explosive 
nature. The wound of the chin, as shown in fig. 13, healed of its own accord, 
without any operation (see fig. 14), while the wound of the left antrum healed with 
a large depressed scar which was treated by excision of the scar tissue, and by 
rolling in fat-flaps, as described in the chapter on Principles. It will be noted that 
the patient's left eye was enucleated in the early stage by the ophthalmic specialist 
on account of the injuries it had received. The scar tissue was widely excised 
under general anaesthesia, and local fat-flaps were turned in to fill up the missing 
contour and sutured with catgut, the skin being united with interrupted horsehair 
stitches. The photographs, taken on the patient's discharge from hospital, show the 
result of this simple procedure. 

In criticising this result, it appears obvious to me that the whole scar was not removed, 
and that, had palpation been made, the edges of the wound would have felt hard and un- 
yielding. The consequence of leaving this indurated subcuticular area is that the edge 
has remained heaped up in places, and does not lie as flat as it would otherwise have done. 
The condition is, of course, eminently suitable for further treatment in the way of re-excision, 
but such would probably have been unnecessary had the above-mentioned precautions 
been taken in the first instance. However, even when the whole scar tissue is successfully 
excised, the first operation scar is not usually as good as when a second or even a third 
linear excision is undertaken, suitable intervals being allowed to elapse between operations. 


CASE 37 

This officer received a long, gashing wound of the left cheek, which is well illustrated. 
At its maximum depth, it penetrated to the mouth (buccal fistula), and, during the course 
of the missile, the mandible was fractured with loss of bone, mainly alveolar. Two pointed 
ends of the lower border of the bone remained in close proximity in the bottom of the wound, 
and at the later operation scar tissue was excised between these points, which were them- 
selves freshened. Combined with dental splinting and necessary extractions, this freshening 
resulted in bony union, so that the injury may be classed as one without loss of bony contour. 

The healed condition in a case like this is merely one of a very large depressed scar. 
The good result obtained was due, I think, to the use of fat flaps, as previously explained 
and as the diagram represents. On this occasion they were rolled in towards the depression, 
having their blood supply from the deep tissues : the skin, thus undercut, was drawn over 
the fatty prominence and accurately sutured. The skin edges were cut markedly on the 
slant or bevel, and the stitch used was the semi-subcutaneous horsehair mattress suture 
(vide p. 33), reinforced by a few edge-to-cdge stitches. The upper part of the scar was 
invisible as such before this patient left hospital, but there was still a slight depression 
which marked its site. 

The final history of this gallant officer from the Dominions is pathetic. Soon after 
being posted back to duty he volunteered for foreign service again, was shot through the 
knee-joint, and died of wounds in the same Casualty Clearing Station as that which received 
him when his face was wounded. 



i g. On admission 10 days after wound. Lower 
facial paralysis. 

Fid. 1G represents^fat flaps rolled in towards 
the centre of the depression. 

FIG. 1 7. Result. Note : the smudge beneath the 
chin was a result of shaving, and has been removed on 
the print. There was no appreciable facial paralysis 
at this stage. 


Literally one might give hundreds of examples of these scars and of the 
results of their excision, and I need only here refer to my remarks in Chapter 
I, p. 33, where I have discussed the production of invisible wound scars. 



Here, again, the definition of this class can be no more than arbitrary, 
as some of the examples are merely extra large depressed scars, while others 
include in their lesion a loss of bone. They may be described as cases 
requiring the provision of flaps, but not including any serious operation for 
the restoration of the lost bone. 

CASE 27 

Gunner P. was wounded 22.7.16, and admitted to me on 10.12.16, in the healed 
condition, as shown in fig. 18. There was a large loss of soft tissue involving the 
left corner of the mouth and the region of the cheek extending outwards from this 
corner. The wound had healed by scar tissue, and besides considerable deformity, 
there was much loss of function through contraction. The first operation I per- 
formed on 10 . 1 . 17 was a complete failure, due entirely to a haematoma which 
formed under the flap. The flap had to be raised in order to evacuate the blood : 
none of the stitches held. The condition when healed, after this unfortunate occur- 
rence, was practically the same as on admission, but 
with one additional scar. On 5.3.17, the con- 
dition had been healed so long that a second 
operation was judged to be possible. On this 
occasion a large thick musculo-cutaneous flap, in 
breadth about 1 in., was taken from the left naso- 
labial and left infra-orbital regions and swung down 
towards the corner of the mouth (where, after 
the excision of the scar, there was a large deficiency 
of skin and muscle), as shown in the diagram, 
fig. 20. The scar tissue excised at the corner 
of the mouth included about a third of the upper 
lip, and did not penetrate farther than the deep 
surface of the mucous membrane of the mouth. 
On attempting to fit the flap in at the corner of 
the mouth, I realised that it had to be split, the 
larger portion going to the upper lip and the 
smaller to the lower. 

Another interesting point in this case is to 
be observed in the fact that a large flap can be 
taken from this region without causing serious 
secondary deformity. The result of this operation 
was very satisfactory, and the value of a split 
flap at the corner of the mouth is established 
by this case and by Case 220 (page 56). This 
-Actual loss greater than apparent. patient was discharged from hospital on 1-1.5. 17. 



Fio. 19. Flap. 

FIG. 20. Suture. Note splitting of flop to form 
angle of mouth. 

FIG. 21. After plastic. Lips apart, lower scars 
not treated. 

FIG. 22. After plastic. Lips closed. Split flap 
to form corner of mouth. 

1 1 


CASE 292 

Fig. 23, of this case represents the condition of Sergeant 15. on admission into 
this department on 15.6.17. IK- was wounded on 10.9.10. Previous notes and 
photographs are not available. lint it is obvious that he had a shell wound pene- 
trating the left antnmi, with the loss of infra-orbital plate, and a large depressed 
scar on cheek. The sear was excised on 14.7.17, under general anaesthesia, and a 
large fat graft, measuring .'5 in. by 2| in. by ? in. thick was taken from left buttock 
and fixed" in the depression by "catgut. Everything proceeded normally until the 
fourteenth day, when first fat necrosis, and subsequently suppuration occurred. 
necessitating drainage from the centre and from the dependent portion of the sear. 
This suppuration continued for about four weeks. His condition when the suppuration 
ceased is shown in fig. 24. I illustrate this case to show that, although a fat graft 

Fia. 23. On admission healed. 

FIG. 24. Left eye enucleated. Fat graft to cheek. 

may not succeed in toto, yet, even if it suppurates, very considerable improvement 
in the contour is invariably produced. In order to complete this case, it appeared 
advisable to implant a cartilaginous plate to take the place of the lost infra-orbital 

At the same time, it. was decided to utilise a piece of cartilage for a prosthesis 
of the eye socket, which was of a very shrunken character. 

Two operations were therefore carried out at the same time on 10.9.17. An 
incision was made parallel to the lower lid and over the infra-orbital margin, and the 
skin undermined in the neighbourhood. A piece of cartilage, composed of a portion 
of two adjacent rib cartilages, was removed for me by Captain H. Montgomery, 
H.A..M.C.. IVoni this patient's right thorax, the attachment between the two rib 
earl Mages being left undisturbed. It was pared with the knife until it was of such a shape 
that the (( ml our was accurately reconstructed, placed in position, and the skin reunited 
over it with siibcut icular horsehair. The sternal end of the 7th cartilage was then taken, in 



its whole thickness, and shaped into a cup and ball, as described in the chapter on Eye 
Plastics, p. 339. These two pieces of cartilage were inserted into the depths of tin- 
eye-socket through an horizontal incision made in the conjunctiva. The two wounds 
healed by primary intention, and, after the fitting of an artificial eye, the result was 
very satisfactory. Diagrams illustrating these later operations are appended. 

FIG. 25. After cartilage grafts to socket and cheek. 
Artificial eye fitted. 

Flo. 26.- Ditto. Same stage< 

Sec tion 

, Prosthesis, 

of L. Socket 

\ X 7 C M Costal 
N 8 ^[Cartilage 

FIG. 27. Diagram of cartilage implants. 



CASE 73 

Represents a type of case in which there was partial loss of the malar bone and 
fracture of the lower jaw. The deformity is not one which calls for definite recon- 
stitution of the bony framework. 

Private C. was wounded on 1.7.16, and his condition on admission on 6. 7. 1C 
is shown in fig. 30, the result of a severe shell- wound. On 29.11.16 Lieutenant 
C. B. Tudchope, R.A.M.C., performed an operation. The large scar, extending from 
the outer orbital angle to half an inch below the lobule of the left ear, was 
excised. The fibrous tissue was so thick that the dissection led down to the remains 
of the malar bone and horizontal ramus of mandible. This dissection completely freed 
the lobule of the ear. In order to build up the contour, local fat-flaps were turned 
in and sutured with catgut but, owing to this being insufficient, a small free fat-flap 
from the buttock was implanted. The wound was closed by relaxation and horse- 
hair sutures, without drainage, the lobule of the ear being adjusted to position. 
Moderate suppuration of this fat-graft occurred, but the condition shortly before 
discharge was as shown in fig. 31. The fracture of the lower jaw necessitated the 
patient's stay in hospital for a longer period, and he was not discharged until 21.4.17. 
It is obvious that this wound involved the destruction of branches of the temporo- 
facial nerve. 


Fio. 28. " Natural " flaps made by excision of scar. 

Fio. 30. Five days after wound. 

Fia. 31. Result plastic. Note : upper facial paralysis 



CASE 33 

In this case the wound of the left cheek was complicated by loss of bone in the upper 
jaw. The wound also extended from the left corner of the mouth and opened widely into 
the buccal cavity. Unfortunately I have no record of the healed condition, and in view 
of one's experience, this spectacular result is to be, to a certain extent, discounted. The 
first operation (27.10.16) was performed three months after his shell- wound. The aim 
was to reform the corner of the mouth, adjacent portions of both lips, and a considerable 
amount of check ; and a large dense scar had to be excised. The mucosa was carefully 
dissected and sewn to reform the buccal lining and to complete the upper lip. My notes 
read that there was much less loss of tissue than was expected. 

The result was gratifying, but as a considerable amount of scar tissue remained on the 
edges after excision of the main part of the scar, the line of union was not expected to be 
perfect. A particular twist of a mucous flap satisfactorily formed the corner of the mouth, 
and the wound healed well. 

Two months later, a second operation was performed : the scar was excised, and fat 
flaps sutured beneath the line of incision, which was closed with horsehair sutures. In 
order to complete the case from a dental point of view, an extensive incision was made 
along the left alveolar border of the maxilla and a vulcanite plate inserted, held in 
position by elastic traction from a dental splint. 

A denture was then adapted to the upper jaw, but I heard later from the patient that 
it had to be altered, which probably meant that scar tissue was reforming (vide notes of 
case 128, p. 60). Patient discharged on 14.3.17. 

FIG. 3-. Soon after wound. 

Fia. 33. Result of plastic. It is unfortunate that 
the healed stage of this case was not recorded. 



CASE 41 

This is an example of a large soft-tissue de- 
struction of the cheek and upper lip together 
with a small loss of the underlying alveolar bone 
of the maxilla. The tip and left ala of the nose 
arc likewise shot away ; but the interest of the 
repair is confined to that of the check. The first 
photograph shows the suppurating and granula- 
tion stage of the wound 10 days after the injury. 

Two months later the plastic operation was 
performed, by which time the wound had healed 
by dense scar formation. This latter was freely 
excised, and the picture on the operating-table 
after such excision very closely resembled that of 
the original wound. The repair was made by 
transposing a large flap (A) from the side of the 
chin and submaxillary region of the same side, i.e. 
an ascending flap. Despite a mild infection, the 
repair was good. The secondary gap caused by 
raising flap A was closed with some difficulty, 
which was somewhat eased by 'a secondary in- 
cision (X) represented too short in the diagram. 

No attempt at rhinoplasty was performed at 
this stage, but later an effort with small local flaps was made to modify the nasal defect with 
but poor result. There is no question, in view of the later development of rhinoplasty, that 
an excellent repair could have been effected on the lines of a turncd-in flap, to complete 
the lining of the tip and left ala, and of a covering from the left frontal region carried on 
a tube-pedicle flap, as in case 627, p. 244. Patient refused further treatment. 

FIG. 34. Wounded, 1.7.16. Condition, 1 1 . 7 . 1 G. 

Via. 35. Result 4 weeks after operation, per. 
formed 19.9.16. No attempt at rhinoplasty. 

FIG. 30. Excision and flaps. 



CASE 144 

" Loss of soft tissue without serious loss 
of the underlying framework " is the category 
in which I put this case. The patient was 
wounded on October llth, 1916, and was 
admitted to me on 17.10.16. The wound 
is a very remarkable example of the explosive 
type and it is instructive to note how this 
patient's enormous gaping wound healed 
without more than ordinary surgical methods. 
I think this case teaches a lesson to the in- 
experienced in regard to the way the camera 
occasionally represents an inaccurate concep- 
tion of the wound. Thus, fig. 38 repre- 
sents the condition when the tissues were 
healed, without any plastic operation what- 

The further treatment of this case was 
undertaken by Captain J. L. Aymard, 
R.A.M.C., and consisted of excision of scars, 
with satisfactory results. 

FIG. 37. Condition on admission. 

FIG. .'{8. The result of healing without any 

Fia. 39. After 1st excision of scar. Note : no general 
facial paralysis. 



CASE 296 

This case, Private W., wounded on 1.7.16, and admitted a week later, is an 
example of buccal fistula situated in the exit wound of a bullet which entered the 
left check and carried some teeth through the right cheek. In fig. 40 is shown the 
exit wound with buccal mucous membrane everted through the hole. The corner of 
the mouth just escaped destruction. This is one of the cases in which early opera- 
tion is indicated. 

An operation was performed on 21.7.16 under general anaesthesia. The buccal 
mucous membrane was dissected up, invaginated, and retained by two rows of purse- 
string sutures. Accurate suture of the rest of the wound was not attempted at this 
stage, but approximation of the skin was produced by means of the method shown 
in fig. 41. Pieces of blanket flannel, to which are sewn dress-hooks, are fixed 
with collodium to each edge of the wound and the hooks are then united by rubber 
bands. Drainage was provided. This method, as advocated by Kazan jian, is very 
valuable in the early approximation of wounds when deep sutures are liable to 
suppurate and to produce more scar tissue than was previously existing. The result 
of this operation was very satisfactory ; no salivary leak occurred and the wound 
healed by good secondary union. There was a long, irregular, depressed scar still 
present at the end of two months. This scar was then excised, but there was a slight 
breaking-down near the angle of the mouth. The scar was re-excised some six weeks 
later. The result, as shown in fig. 42, was practically perfect and the man was 
discharged from hospital to duty on June 13th, 1917. 

Fid. 40. Buccal fistula. 

FlO. 41. Use of approximating hooks 
and clastic (Kazanjian). 

FIG. 42. Result of plastic and 
excision scar. 



CASE 101 

Lance-Corporal W., wounded on 7.10.16, was operated on by me on 15.1.17. The 
wound involved part of the malar and zygomatic ridge. It will be noticed also that botli 
eyelids are involved in and dragged outwards by the scar. Two flaps were raised on each 
side of the scar ; from the lower a local fat-flap was turned upwards, while from under 
the upper flap a small portion of the temporal muscle, with its overlying fat, was turned 
downwards. The result as to the contour was good, as is shown in fig. 44. Under local 
anaesthetic four months later, an attempt was made to release the eyelids from the outward 
drag. This was only partially successful, the method used being to make an incision \ in. 
external to the outer ocular angle, \ in. in length across the line of the scar and to sew up 
this perpendicular incision horizontally. To further raise the scar a small tunnel was made 
from this incision in a backward direction and a small amount of paraffin wax imbedded. 
This was only partially retained. 

I do not consider that either of the last procedures is to be recommended. In order 
to release the outer canthus correctly either a flap should have been laid in between the 
end of the scar and the outer ocular angle, or else a sufficiently large skin-graft applied to 
produce the same effect. 

In regard to the insertion of paraffin, I cannot express too strongly my disapproval of 
using this irritant foreign body. Undoubtedly the best method of using paraffin is to imbed 
a definite quantity of it into a prepared pocket. The immediate results are often very 
pleasing. But there are so many examples known to all surgeons of chronic thickening 
of the parts, induration of the skin, paraffin tumours and other complications, that its use 
should be strongly deprecated, not only in this work, but also in all forms of civilian cosmetic 

Flo. 43. -The healed stage. Loss of bone in malar 
region. Outer canthus dragged out by scar. 

Fio. 44. Result after an attempt partially successful 
to relieve the drag on the outer canthus. 



The severer injuries of the cheek include those in which there is loss of 
the bony frame-work. One particular group (1) is well defined, viz., that in 
which the malar prominence is wholly or sub-totally lost. I have chosen 
to illustrate this group by four cases which have been treated by means of 
the temporal muscle turned forwards subcutaneously. In one of the cases 
(40) a previous unsuccessful implantation of a celluloid plate was made and, 
in the following case, a thin celluloid plate was inserted over the temporal 
muscle flap with satisfactory results. 

CASE 28 

This patient was received in a healed condition on 18.5.16, as shown in fig. 45. 

He was wounded 26.9.15, eight months previously, no record being available 
as to his previous condition. On 30.6.16 I operated under general anaesthesia. 
After excision of the scar, an extension of incision into the temporal region enabled 
me to detach the anterior two-thirds of the temporal muscle. This muscular flap 
was separated from the rest of the muscle and swung down into the depression 
caused by the loss of the malar prominence, in which position it was sutured 
with catgut. The lower part of the wound was filled up by means of local fat -flaps. 
Horsehair was used for the skin edges. In fig. 47 the result of this operation is 
shown. The dimple underneath the left eye is due to the deep suture above referred 
to, which retains the temporal flap in position. Primary union followed this operation. 
1 was not satisfied, however, with the reconstitution of the left orbital margin ; 
hence, a piece of shaped rib cartilage from the right thorax was taken and inserted 
subcutaneously to form the outer orbital margin. An acute infection followed this 
operation, performed on 21.7.16, which owed its origin to the proximity of the 
orbital cavity, and the graft was removed to avoid the possibility of orbital cellulitis. 
The condition rapidly cleared up and on 7.9.16 some of the scar tissue was excised 
under local anesthetic (novocaine). On 14.10.16 a final operation was performed for 
the still further improvement of the contour and scar. The upper part of the vertical 
scar was excised, skin cut on the slant, and a bed made for a triangular smooth 
piece of celluloid, which was implanted. The skin edges were carefully sewn up 
with horsehair. The result of these operative procedures is shown in fig. 46. 

An interesting after-history of this case is that, on 26.3.17, this man was re- 
admitted suffering from a localised abscess over the centre of the celluloid plate and 
line of the scar. The abscess was located between the celluloid and the skin and 
had not burst. The celluloid plate was freely movable and the abscess was not painful. 
Within a week suppuration had ceased and the patient was again discharged with 
the celluloid plate still in place. It is interesting to note that this is one of 
the few celluloid-plate implantations which, in my experience, have been retained. 
Another point of interest in connection with this case is the suppuration following the 
cartilage graft operation. In view of later experience with cartilage, I believe that 
had this suppuration been drained, there is the possibility that a large amount of the 
cartilage might have been retained, and that I was over hasty in its removal. 



FIG. 45. Healed condition. 

FIG. 46. After insertion of thin celluloid plate. 

Fid. 47. Soon after temporal muscle implant. 


CASE 40 

Is the next example of this group. The healed condition of this case will be seen 
in fig. 48. Private F. was wounded on 7.7.16. The wound caused loss of the 
right eye part of the lower lid and the malar prominence, combined with the external 
portion of the orbital ring. At that time I was giving celluloid plate implantations a 
thorough trial and a piece of celluloid i in. thick was cut in the shape of the missing 
bony substructure and implanted in situ. The result was a failure, as ha?matoma and 
suppuration followed, and the celluloid had to be removed. On 30.1.17 it was possible 
to perform a second operation. After excision of the scar, the temporal muscle flap 
was swung down in the usual manner to make good the contour but, in this case, 
I improved the operation by making the temporal incision in the hairy scalp. This 
" inverted U " shaped incision is shown diagrammatically in fig. 50 and the earlier result 
of this particular operation is shown in fig. 52, while the later result of the implantation, 
witli the addition of an artificial eye, is to be seen in fig. 53. 

FIG. 48. The healed condition showing 
large malar loss and dragging down and 
out of the outer canthus. 

Celluloid. Kiji 

FIG. 49. The first operation included the im- 
plantation of a shaped piece of celluloid. Failure. 

It should be noted that, in swinging this temporal muscle forwards and downwards, 
the intervening skin had to be undermined and raised to allow the muscle to be passed 
underneath it. 

Care must be taken to detach the temporal fascia from its zygomatic attachment. 
When this is completed the muscle flap usually comes forward as far as is necessary. In 
some cases I have advanced it considerably further by dissecting downwards towards the 
coronoid process, at the back of the muscle-flap. When this is done, the end of the muscle- 
flap can be easily stitched to the periosteum at the side of the nose, vide Case 215, p. 71. 
Even in this situation the temporal muscle continues to contract. 

Two months later a small operation was performed to raise the lower lid at the inner 
and outer angles. At the outer angle a small skin-flap was turned into the socket after the 
adhesions were dissected out, while at the inner angle a small wedge-shaped piece was 
removed to bring the angle more towards the middle line. This enabled an artificial eye 
to be carried, but was not entirely satisfactory. 

The result was perfect as far as the contour was concerned, and the temporal 



muscle, in its new situation, had a certain amount of contractile power, thereby giving 
expression. The eye socket and lower lid need further improvement. 

This case has recently been seen, eighteen months after the temporal transplant 
operation, and the contractile power of the muscle is undiminished. 

I MS, 

FIG. 50. Incision and preparation for the author's 
operation for temporal muscle transplant. 

FIG. 51. The flap of muscle sutured into 

FIG. 52. Soon after operation. Showing " U " 
temporal incision. Note the excellent contour. 

FIG. 53. Later. Artificial eye fitted. The 
lower lid still requires raising. 



CASE 220 

Wounded 27.2.17. First operation, 27.6.17. After excision of scar, a flap (fig. 55) 
was swung up, and split to enclose the corner of the mouth, the larger portion going to the 
upper lip, the consequent gap being filled by advancement of flap ('. (figs. 56 and 57). 
Skin and mucosa were sewn separately, to ensure a lining. Mattress sutures were employed 
down as far as the upper lip. One or two edge-to-edge sutures were added in the middle 
of this part, the result being best here. Elsewhere interrupted sutures were used, giving 
a better scar than where mattress sutures were used alone. I do not condemn mattress 
sutures because of this experience, as I find that a scar in the temporal region is usually 
more marked than one in the mouth region. But I think mattress sutures should be assisted 
by the addition of edge-to-edge sutures. The upper six mattress sutures were of thread ; 
hence, possibly, the prominence of this part of the scar, the result being otherwise good. 

An observation should here be made that in planning the flap for the upper lip, I allowed 
slightly for contraction. None has occurred, and I assert that where no raw surface 
is exposed, none will occur ; and the teaching that the flap should be cut one-third or more 
larger than the gap would appear erroneous. When an epithelial or mucous lining can be 
provided, the flap should be the exact size of the gap. The only modification I make on 
this has been discussed in Chapter I. I do not think it advisable to undertake plastic 
operations involving mucous cavities without seeing that the complete lining is available. 

A second operation on 13.3.18, consisting mainly of excision of the redundant portion 
of the flap above described, resulted in great improvement of the line of the lip. At the 
same time, an ovoid piece of cartilage, from another case, was inserted into the eye socket 
through the usual conjunctival incision. The result, after fitting an artificial eye, is shown. 
The lower lid needs raising a trifle. 

t'ia. 04. Recent wound of cheek and upper lip. Fio. 55. Diagram of excision of scar and of flap, A B. 



FIG. 56. Flap, A B t raised and split to form corner 
of mouth. 

FIG. 57. Suture. Flap, O, advanced to fill gap. 
Note relaxation buttons. 

Fio. 58. Day after operation, showing relaxation 
buttons and horsehair mattress sutures. 

FIG. 59. Final result. Lack of muscle power 
in lower lid spoils the eye effect. 


CASE 192 

Is interesting from the point of view of the very large hollow produced by the loss 
of the malar prominence, infra-orbital plate and adjacent parts of the superior maxilla. 
Though wounded on 24.8.16, this patient was not admitted until 9.3.17, when the 
photograph, fig. 60, was taken. Temporal muscle operation was performed on 16.4.17, 
but the operation had to be modified by the addition of a skin-flap. It should be noted 
that there was a small sinus leading into the left antrum at the bottom of the scar and 
the lower lid as well as the left eye had been shot away. The flap of skin was turned 
down from the left temporal region from the line of the temporal artery. It is marked 
" A A" in Professor Tonks's diagram, fig. 61. This flap was slightly bigger than 
is represented and was swung down beneath the eye. In order to fill the gap caused 
by the removal of this flap, a swinging flap B was taken from the scalp. The whole result 
was a very marked improvement. On arriving at the condition shown in fig. 62, one 
has brought into the bounds of possibility the question of the reformation of the left eye 
socket. A certain amount of movement is again present in the transplanted muscle. 
The secondary closure of the temporal region has resulted in an advancement of the hairy 
scalp a condition which is not an unpleasant one. 

The lymph-oedema of the upper lid gradually diminished. The treatment of the 
eye socket was carried out for me by Captain C. F. Rumsey, R.A.M.C., who did a Tripier 
operation, i.e. swinging a stirrup of skin from the upper to the lower lid, the flap ends 
remaining attached for the blood supply to both ocular angles. The resulting condition 
was such that the socket could retain a glass shell. 

At this stage the patient was discharged from the Army, to return later for the com- 
pletion of the eye socket. 

Fid. 60. The healed stage showing large malar, 
and infra-orbital bony loss of lower lid, etc. 

FIG. 61.- Shows author's temporal muscle-flap being 
brought into position, and a temporal skin- flap, A A, to 
be swung down beneath eye to A' A'. 



The further treatment will probably consist of the insertion of a thin strip of cartilage 
into the lower lid to retain it at a correct level. It may be necessary to deepen the socket 
by means of an epithelial inlay. 

FIG. 62. Result of this operation. 

FIG. 63. Result of Tripier operation. 

FIG. 64. Incision for Tripier operation. 

FIG. 65. Suture. 



CASE 128 

Is not unlike the one which directly precedes this. Rifleman B. was wounded 
on 3.9.16 and admitted shortly after this date. No photographic record of the 
condition at this stage is available but on 15.2.17, the day of operation, the 
deformity was as is to be seen in fig. 66. The outer third of the left upper lip was 
drawn upwards and inwards and bound down against the ala of the nose, leaving a 
triangular opening in the cheek with the base downward. The apex of the triangle 
"|K'iis into the antrum while a large scar radiates out into the cheek from the outer 
extremity of the gap. The lower lip is involved in this cicatrix and is drawn 


Operation was performed on 15.2.17. The scar tissue was excised and the 

lips freed. A small flap of skin from the 
upper and lower margin of the gap was turned 
to complete the epithelial lining of the aper- 
ture, so as to prevent cicatricial contraction 
later. To meet this inverted epithelial flap, 
a mucous flap was drawn up from inside the 
left cheek. The mucous membrane at the 
angle of the mouth was completed by swinging 
round a portion of the lower lip and suturing it 
with deep catgut and superficial horsehair 
sutures to the free edge of the upper lip. 
Diagram 67 illustrates the method of freeing 
the upper lip. The corner of this lip was 
brought down to help to form the corner 
of the mouth. The flap was then outlined 
and swung up to complete the closure. It will 
be observed that in fig. 68, a vulcanite support, 
taking the place of the alveolar margin where 
it was wanting, has been fitted by the dental 
surgeon. It was retained in position until the 
wound was well healed, which occurred with- 
out untoward symptoms. Black silk was used 
on this occasion to unite the skin edges. 
(25.1.17.) Some intra-buccal adhesions were 
cut by Captain C. F. Rumsey to allow a 
satisfactory denture to be fitted. Photograph, 
fig. 69, shows the condition on 16.7.17. 

In regard to the cutting of intra-buccal 
adhesions, I feel very strongly that this is a 

method which docs not often succeed ; more frequently than not it produces more scar 
tissue than before the treatment, and anything in the nature of an extensive freeing of the 
lip or cheek by the underlying bone by undercutting and insertion of a dental appliance is, 
in my experience, doomed to failure. I admit, however, that where the loss of mucous 
membrane is minimal and where there is a definite band of scar tissue this can sometimes 
be dealt with by this method. In all other cases recourse should be had to the epithelial 
inlay method of Esser. 

Fio. 66. The healed condition, 15.2.17. Note 
the shield on the obturator, also the iodius which 
spoils the photo. 



FIG. G7. Scar excision and incisions. The inverted 
skin and mucous membrane flaps cut to complete the 
lining are not shown in this diagram. 

FIG. OS. Suture. 

Fia 01). Result, 16.7.17. 



CASE 14 

The illustration, fig. 70, is an example of a very extensive cheek wound with 
loss of the supporting bony structures, especially of the superior maxilla. The corner 
of the mouth and left half of the upper iip were involved in the destruction. 
Wounded in the battle of the Sommc, the first plastic operation was pcrfoimcd thice 
months later, on 4.10.16, on which date the condition is as shown in fig. 71. Dur- 
ing this period the dental surgeon had made successful efforts to reduce the fractures 
of the upper and lower jaw and the healing process apparently diminished the loss 
of tissue. However, on excision of the scar, there was a very extensive gap, not 
considerably less than that shown in the original wound photogiaph. To meet this 
difficulty, two large flaps both of a swinging variety were taken. The larger one, A, 

comprised the remains of the soft tissues of the 
cheek and was defined by means of an incision ex- 
tending from the side of the nose and carried outwards 
beneath the eye to the malar prominence; while 
the lower flap, B, was outlined by an incision carried 
down from near the corner of the mouth to below 
the mandible in the sub-maxillary region. These 
two thick flaps were widely under-cut and swung 
towards each other ; the upper flap completed the 
gap above the level of the mouth, while the lower 
one was sutured along its lower border. Owing to 
the large deficiency of mucous membrane, it did 
not seem possible to complete the mouth in its 
original size and some sacrifice in length of the lips 
was perforce made. Relaxation sutures were inserted 
to retain the untouched part of the lower lip to the 
large cheek flap. Drainage was provided at a suit- 
able spot. The result of this plastic operation was 
very satisfactory in so far as one operation pro- 
duced a result which satisfied the patient ; but it 
left the man with a whimsical, one-sided expression 
which, however, was not entirely unpleasant. The 
rest of the treatment for this patient consisted in 
the effort to get union of the right horizontal 
ramus of the mandible. An extensive freshening 
of the ununited fragments was carried out on 11.1. 17, 
but no union resulted after a period of three 

months. On 25.4.17, the fracture ends were again exposed but, although found to be in 
good apposition, there was no bony union. The surfaces were again freshened, drilled 
and wired together with strong iron wire. This operation was carried out by Captain 
J. L. Aymard, R.A.M.C., and Captain F. E. Sprawson, R.A.M.C. No union had occurred 
at the end of two months but, at the end of five months, there was clinical union 
of the fracture and the patient was fitted with an upper and lower denture which 
enabled him to eat a semi-solid diet. He was discharged from the Aimy unfit for further 

FIG. 70. Showing condition a few days 
after wound on 1.7.16. Compare this with 
the healed stage, which gives a truer con- 
ception of the loss of tissue. 



FIG. 71. The healed condition, 4.10.16. 

Fio. 72. Diagram showing excision 
of scar and flaps cut. 

Fio. 73. Suture. 


Fio. 74. Early result operation, October 1910. 

Fio. 75. September 1917. 



A less defined group is one in which the bony support of the upper jaw 
is missing. The loss of bone may be in the alveolar process, the anterior wall of 
the antrum or in the infra-orbital plate. When the combined bone and skin 
lesion is not great, the difficulties are overcome with very satisfactory results ; 
but when there is a great loss of both soft and hard tissues, as in Case 215, 
the problem is one requiring much thought. 


This man was wounded in the upper jaw and cheek, including the corner of the 
left upper lip, by a shell, on 1.7.16. The bony loss consisted of the alveolar process 
and the lower part of the antral wall. The condition cleared up sufficiently to allow the 

FIG. 70. On admission three weeks after wound. 

first plastic operation to be peiformed on 29.9.16. The irregular scar was widely excised. 
The gap produced by this excision is well shown in diagram, fig. 78. In order to close 
this gap a large swinging flap, A' B', was swung upwards to meet A B, and the mucous 
membrane at the corner of the mouth was rearranged. On 2.11.16, some six weeks 
later, the scar tissue was excised and fat-flaps brought to fill up the hollow ; this was 
sutured with catgut, the skin with horsehair. The final result, seen in fig. 81, is 
sufficiently satisfactory. When fitted with dentures on discharge from hospital, the 
patient was able to eat most articles of diet. 



FIG. 77. The healed condition. 

FIG. 78. Diagram representing excision FiQ. 79. Diagram 

of scar and cutting of flap A' B'. of suture. 

a. 80. Result of operation, 2(1. 9.1(i. 
Intermediate stage. 

Fid. 81. Result of operation, 2.11.16. 
Photo taken, 2 1.11. 1C. 



CASE 142 

The early condition of Private R. C., of the Scottish Rifles, wounded on 1.9.16, 
is represented in the accompanying figure 82. The condition had so far cleared 
up that I was enabled to perform the first plastic operation five weeks after this 
patient was wounded. Unfortunately the photographic record of his healed con- 
dition is missing. Too much was not attempted and the result was sufficiently 
satisfactory. Fig. 88 shows the result of this operative procedure, of which 
records were not accurately kept. But the large hole in the left cheek, involving 
the angle of the mouth and a portion of both lips, was closed by two swinging 
flaps, one from above and one from below. A further plastic operation was per- 
formed by me three months later and, here again unfortunately, the details are not 
available. The condition after this, when healed, is as shown in fig. 83. At this 
.stage, Captain Aymard undertook to finish the condition. After excising the scar, the 
lip was raised and sewn by the method shown in Professor H. Tonks's diagrams, the 
result being all that one could expect. 

Fio. 82. Wounded on 1.9.16. Showing condition 
a few days later. 

FIG. 83. Showing result of two plastic operations 
(author), 10. 10. 1C and 3.1.17. 




FIG. 84. Diagram (Tonks) of operation to raise corner of mouth. 

FIGS. 85 and 80. To show result of operation, 13.3.17 (Aymard). 



CASE 49 

Is another example of the ravages of shell. This private of the Royal Minister 
Fusiliers, whilst still in the condition shown in the photograph, fig. 87, was found 
one morning looking in the mirror and smiling with the remaining side of his face. 
His excuse for his amusement, he explained to his medical officer, was that he was 
thinking " phwhat an aisy toime the barber would have in future." This is charac- 
teristic of the cheerful resignation of face cases in general. The extensive injury in 
this patient comprised a large loss of substance of the left cheek, corners of the 
mouth and upper lip, together with the anterior and inner walls of the left antrum 
and alveolar margin. Strong cicatricial bands formed between the maxilla and 
mandible, the body of which was likewise fractured. An injudicious attempt to 
form the mucous lining of this cavity was made on 26.10.16 without, at the same 
time, closing in the gap by skin-flaps. Although the operation was carried out with 
great care and accuracy the want of skin covering over the mucous membrane flaps 
led to mal-nutrition of the mucous membrane and the giving way of the stitches. I 
have tried this method of building up the lining at a separate sitting to the covering 
both of mouth and nose openings, but have not had satisfactory results. Both lining 
and the covering should be done at the same time or, if it is impossible to find a 
lining, the covering should be epithelialised first. On 6.1.17 the patient still 
showed a very deep depression on the left side of the face, communicating widely 
with the nasal cavity. Much granulation and scar tissue was present, involving the 
left portion of the upper lip. The covering to this gap, after extensive excision of 
scar, was formed by two advancing flaps from the cheek, as indicated in the dia- 
gram, fig. 88. Similarly, the upper lip was cut across below the nose and sutured 
to the freshened surface beyond the angle of the mouth and, to round off the angle, 
a small mucous flap was turned upwards from the lower lip. An attempt was then 
made, by means "of a free muscle graft taken from the vastus externus, to close 

over the hole into the nose and to fill up the 
contour. The closure was then completed, a 
relaxation suture being used to relieve the tension. 
The whole of the muscle graft became infected 
and apparently sloughed out. This is borne 
out in other similar experiences where the graft 
is exposed to a mucous cavity. Its place, how- 
ever, is taken by granulation tissue and later 
fibrous tissue which very materially aided in the 
final treatment and enabled me, three months 
later, to implant a piece of cartilage to make 
good the loss of contour. At this operation, 
date 11.4.17, there still existed a small per- 
foration into the nose which was closed by 
turning in over it small scar tissue flaps. A 
plate of cartilage about 2 in. by 1| in was 
taken from the right thoracic wall. The result 
of this implantation was satisfactory from a 
cosmetic point of view but, surgically speak- 
ing, it was not gratifying on account of a 
small leak into the nose, causing later infec- 
tion of the graft. The infection was of a 
mild character, however, and was controlled by 
Hicrs cupping. The result is shown in photograph, 
FlG. 87. Healed, 20.10.18. fig. 90. 




Fia. 88. Scar excision and flaps. FIG. 89. Suture. 

Note : another incision along the upper lip is missing in the diagram. 

FIG. 90. After plastic and cartilage implant. 


CASE 105 

Is a typical example of the shattering effect of an exit wound of a high velocity 
projectile which came into contact with a dense piece of bone. A considerable 
portion of the right angle of the mandibles as well as the tissues overlying it, were 
blown away, producing a large buccal fistula. After many months of suppuration 
and operations for scqucstrotomy, the wound eventually healed. Bits of the mandible 
had been blown down into the neck and one piece was removed from the right stcrno- 
mastoid. Examination of notes made at the time of the first plastic operation reveals 
that there was a deep scar over the region of the right angle of the mandible and 
radiating in all directions. 

On 16.1.17 this operation was performed. Under general anaesthesia the scar 
tissue was carefully dissected out. Eatty tissue in the form of flaps was swung 
over the deepest portion of the wound and sutured into place. The skin edges 
were completely united with continuous silk suture. Examination on 12.3.17 revealed 
that the result of the previous operation was excellent, except that, from a contour 
point of view, there was too much prominence just anterior to the angle of the jaw. 
On examining X-rays, this prominence was found to be due to the fact that the body 
of the mandible had been split into two halves by the projectile and that the union 
with the ramus had taken place by attachment to the inner plate, while the lower border 
of the body had been deflected outwards and stood out as would an exostosis. It 
was decided to remove this prominence of bone and to cut a flap of thick tissue to 
be swung backwards toward the angle to simulate that prominence. The result of 
this procedure, on 12.3.17, was satisfactory in restoring the contour of the jaw. At 
this time, the right antrum, which was still somewhat infected, was drained through 
the nasal fossa. There still remained a certain amount of scar tissue which was excised, 
at my request, some five weeks later by Captain Ayniard. Owing probably to tin- 
fact that this operation followed too soon on the above, no further improvement was 
obtained, as there was some slight sloughing. 

I think the most astonishing feature of this case is the fact that union of the mandible 
was obtained after such a long period of suppuration and exfoliation of bone. 

The wound was so septic that the idea of early closure was unthinkable. But the 
question arises that if all the pieces of bone that were later exfoliated had been taken away 
in the early stages, in order to clear up the sepsis, would union of the mandible have been 
obtained ? I hardly think so. In my experience, as a rule, this class of explosive wound, 
with buccal fistula, rapidly cleans up on account of the free drainage. But in this ease- 
pieces of bone had been driven down, not only into the sub-maxillary region, but also as far 
back as the sterno-mastoid ; the drainage, though apparently adequate, was not really so. 

Fio. 91. Explosive type exit wound. FI G . 92. After moderately successful plastic attempts to 

improve the contour. 



CASE 215 

One of the most extraordinary examples of loss of contour that I have had under my 
care. Literally the whole cheek and its supports have been blown away ; the left 
lower eye-lid, swollen with lymphatic obstruction and dragged down by scar tissvic, 
is all but joined to the angle of the mouth, which is likewise distorted by the cicatrix. 
Excepting a thin plate of the ascending ramus of the lower jaw, the mandible has 
been destroyed from the first molar region to the joint. The left eye has been enucleated. 
Working in conjunction with Captains C. F. Rumsey and Robertson, under whose care 
this case was placed, it was decided to replace the remains of the superior maxilla 
and mandible as far as possible into their normal positions. An impression of the 
upper jaw is shown in fig. 93, which shows the extraordinary approximation of the two 
alveolar borders. 

First of all, the scar tissue was excised at the left corner of the mouth and 
carried out so that a large opening was made into the buccal cavity. The healthy 
mucous membrane was drawn out and stitched round to the margins, so that there 
should be less scar formation. In regard to the mandible, there was a plate of bone 
representing the left ascending ramus lying inwards from its normal position and 
having no connection with the joint. Its connection to the scar tissue and to 
the anterior fragment of the mandible was cut and, thus mobilised, it took a more 
normal position. As far as the maxilla was concerned, a small chisel was entered 
between the left canine and lateral incisor region and driven backwards along the 
palate without injuring the mucous membrane on the oral surface. This mobilised 
the left half of the palate so that it could be easily replaced into normal position. It 
was held there by a temporary support while a proper cap splint was being made. 
This was fitted in a few days and worn for some months. The impression of the 
palate as it is now, is shown in the accompanying fig.- 94. 

FIG. 93. Model of palate before its forcible 

FIG. 94. Same after the left half of the palate had 
been levered into position and retained there by 

About five months later the plastic operation proper was performed, on 7.12.17. 

The principle of this operation may be described in the following manner : The 
mucous lining was provided by raising the available mucous membrane from below 
and above the gap, as two flaps, and then suturing together. The intermediate, or 
supporting structures, were provided by means of a large temporal muscle transplant, 



Fids. 95 and 96. 
Destruction of the greater portion of the left side of the face. Note the contour. 


Fio. 97. Result of opening up wound and forcibly FIG. 98.- Diagram of flaps for next stage. The 

replacing left half of palate. Retention apparatus in mucous membrane lining is represented by the shading. 
position. C is a post auricular flap. 



7 X 

FiO. 99. Diagram'of the four cartilage implants. 

Fio. 100. Final result. 

FIO. 101. Same. Note the difference in contour 
as compared with the original. 


carried out in the usual manner. The anterior portion of the left temporal muscle 
was detached from its origin and swung down beneath the eye to fill up the 
contour of the check. An incision in the hair line was necessary to get at this 
muscle and it was then possible to undermine the skin from the zygomatic region to 
enable this muscle to be detached. Deep catgut sutures holding this in position had 
for their purchase the left lateral aspect of the nose. The main skin-covering was 
provided by a large transposed flap with its base in the left sub-maxillary region 
and its apex in the left mastoid region. Its design is well shown in Professor Hcmy 
Tonks's diagrams. It met the main deficiency of cheek skin. The area behind tin- 
ear, caused by the removal of this flap, was only partially closed by undermining and 
advancement of the skin and was left to granulate. The flap healed remarkably 
well, as did the granulating area, and this, despite a chronic suppurative otitis media 
which was present in the left ear immediately above the site of operation. The 
healing properties of this particular patient are indeed remarkable. 

There remains to describe the replacement of the eye socket. This was merely 
sutured into a higher level after excision of the scar which bound it down to the 
mouth region. The corner of the mouth was regulated and reconstituted by a special 
cut, which enabled the upturned corner of the upper lip to drop to its normal level. 

Examination in April 1918 revealed the fact that the upper jaw was firm in its 
new position and, with the strip of bone mentioned above, the remains of the left 
ascending ramus of the mandible have become firmly united to the rest of this bone, 
thus producing a very considerable functional improvement as far as mastication is 
concerned. The jaw cannot be opened to its fullest extent but the trismus is not 
of a disabling character. 

Having a large piece of cartilage to spare from another operation case, this was 
inserted subcutaneously over the manubrium sterni, under local anaesthesia. Five 
days later, under general anaesthesia, the cartilage was extracted from its bed and 
divided into four pieces, the largest piece being utilised to complete the contour of 
the mandible. The second, a long thin strip, was inserted beneath the eye socket 
to retain the lower lid at a higher level. The third piece was placed in the external 
orbital region, while the remaining piece was inserted into the temporal region, whence 
the muscle had been taken. 

I am greatly indebted to Major C. W. Waldron, C.A.M.C., for permission to 
complete this Canadian case after it had been officially transferred to him for treat- 
ment and I had the benefit of his advice and assistance at this latter operation. 

It is still doubtful whether a really satisfactory artificial eye can be fitted ; but, 
as this man states he is returning to a very cold part of Canada, and is therefore 
not anxious to have this fitted, the case is now completed. 




THE repair of the upper lip after gunshot wounds is to be considered from 
three main points of view: (1) the provision of the skin-covering; (2) the 
provision of the muscular and subcutaneous layer ; (3) the provision of the 
mucous membrane lining and vermilion border. 

Taking the first of these problems, the skin, the subjects being all men, 
it is a great advantage that your flap should contain hair-bearing follicles : 
this is more especially the case since it is quite unusual to find an upper lip 
that is totally destroyed and does not present portions bearing moustache. 
It would seem, therefore, that the flap of election for an upper lip would be 
an ascending flap with its base opposite the line .of the upper lip and its 
extremity situated in the lateral chin region. This method violates one 
important principle, viz. the direction of the blood supply, as it is obvious 
that it cuts across the facial artery at its division into the coronary arteries. 
It is, however, as a matter of practice, a satisfactory flap, but there have been 
occasions when one has lost portions of it by sloughing caused by scar tissue 
in the neighbourhood of the blood supply, or when it has been cut too long. 
Each case has to be taken as a problem by itself. 

The second main method of making new portions of the upper lip is one 
which includes the use of descending lateral nasal flaps, with their bases in 
more or less the same position as the above-mentioned. 

This flap has the advantage of an excellent blood supply, and shows little 
tendency to depress the corner of the mouth, which is not uncommon with 
the ascending flap. On the other hand, there is no hair-bearing skin in the 
flap, and, if the mucous membrane is to be included, there is only a small 
available amount under the flap, and its length is limited by the undesirability 
of encroaching on the lower eyelid region. 

Transference of hair-bearing skin from a distance is the third method of 
external covering for a lip. Hair-bearing skin is swung down from the temporal 
region, as in Case 324, or from the forehead, or from the temporal region on 
tube pedicle flaps as described in Principles. 



These arc merely methods of getting hair-bearing skin from the scalp to 
the lip, and all have the advantage of introducing new tissue to the region of the 
mouth and of leaving no secondary facial scars. 

A rough comparison of the pros and cons of the three methods follows, 
giving ideas which may be found useful in upper -lip plastics. 


(a) Advantages. Hair-bearing, ample mucous membrane underlying, 

wide mouth. 

(b) Disadvantages. Blood supply less good, more twist, depresses 

angle of mouth if any of lip remains at corner, muscular 
movement indifferent. Scars noticeable. 

(c) Indications : 

(1) When a scar runs up and out from lip. 

(2) When there is accompanying loss of cheek near 

upper lip. 

(3) For half-lips when there is a good half moustache 


Fid. 102. Ascending flap. FiO. 103. Descending flap. 


(a) Advantages. Good blood supply. Angle of mouth not depressed. 

Muscular movement good. Scars negligible. 

(b) Disadvantages. No hair. Shortness of mucous membrane lining, 

apt to be cut too short, and therefore contracts the mouth 
and puckers the lower lip. 

(c) Indications : 

(1) Where a portion of the upper lip remains near the 


(2) When a scar runs down and out from the mouth. 


(a) Advantages. } 

(b) Disadvantages.^*^* th SC f "* ab Ve> 

(c) Indications. When corner and small part of adjacent upper lip 

remains on the one side (diagram, p. 85), and a loss right 


up to the corner and extending to cheek on the other (see 
diagram). This method slews the mouth in toto to one side, 
but has given me one good result. 

See Case 106, p. 84. 
Scalp -flap. 

(a) Advantages, -Provides moustache, and new tissue introduced from a 

distance, no secondary scars on face. The lining may be pro- 
vided at same time by including portion of non-hairy forehead. 

(b) Disadvantages.- Blood supply not always reliable (I have seen 

several failures due to gangrene), no musculature in flap. The 
operation is a considerably larger affair. 

(c) Indications. (1) Where the loss is great and much scar tissue lies 

in and around base of ordinary flaps. (2) In an otherwise 
perfect face where the skin covering only is required. (3) 
After failure of other methods. 

Fio. 104. Temporal artery scalp flap. 

In sub-total and half-lip losses, the same principles are involved, but there 
are a few additional methods which deserve mention. 

(a) The advancement of the remaining portion of the lip to meet 

a new flap. 

(1) Advantages. Second flap need not be cut so long. 

(2) Disadvantages. Very apt to shorten lower lip and to 

make it pout, also to upset the subsequent applica- 
tion of a denture. 

(3) Indications. Small losses, and to make full use of exist- 

ing lip and red margin. No harm is done by this 
incision, and it is a useful manoeuvre provided that 
the corner of the mouth is carefully preserved. 


(b) Advancement with parallel cut through existing corner a larger 

gain of length is obtained than by the simple advancement. 
But derangement of the corner occurs and always requires 
a secondary correction, often an enlargement of the mouth. 

(c) Advancing swing transferring part of lower lip to upper, a new 

corner being made. This method has its uses, but my ex- 
perience with it is not large enough to see clearly its limitations. 
When the cut includes the mucous membrane, the secondary 
deformity is very considerable and difficult to correct ; but 
when the skin only is slid over the deep tissues to the upper 
lip, like one card over another, the secondary deformity is 
not serious either functionally or aesthetically. 

A further method, and probably the best, is available for a loss of the central 
portion of the upper lip. 

(d) An ascending whole thickness flap is let in above, through or 

below the existing third of lip on one side. This depresses 
the angle of the mouth and needs a subsequent correction 
at a later date when a portion of this flap is returned to the 
lower lip to raise the angle. This secondary correction is easy 
to obtain. Several examples are illustrated among the cases. 

(e) The ascending bridge flap with hair for moustache is indicated, 

when skin only is required. The pedicle is returned to the 
cheek. Vide Case 295, p. 114. 
(/) Similarly, moustache bridge flaps may be cut from the scalp 

and swung down to the upper lip with successful results, 
(g) Method of Esser. See Annals of Surgery, March 1917. 
Secondary corrections to the new upper lip are of only too frequent neces- 
sity. I have seldom produced a satisfactory upper lip in one operation. 
Corrections of the level of the mouth corners, of the red margin, of microstoma, 
of adhesions between lip and jaw, and of general tightness, all present problems 
which cannot be usefully discussed at the present time. 

In regard to the second provision for an upper lip, the muscles and sub- 
cutaneous tissue, both the main methods of repair above mentioned provide this 
tissue body for the new lip. Thus, the ascending flap from the chin region 
includes the orbicularis and various portions of muscles attached in the region 
of the chin, while the descending flap has muscular fibres. 

It is doubtful whether either of these muscular flaps gives as much move- 
ment in its new position as the main flap for making a lower lip, which is 
mentioned in the next section. But in both cases a certain amount of muscular 
function appears to persist, It is, however, to be admitted that the move- 


ments of a new lip are very inferior to that of the normal, and as the form of 
the lip depends, to a very great extent, on the normal muscular poise, it is 
obvious that the reformation of a normal upper lip is not, so far, within the 
maximum of possibility. The most that I foresee as a result is a new upper 
lip, which, in a position of rest, gives a normal appearance. The production 
of the filtrum is a subtlety which does not seem to be worth attempting 
until one has produced a higher grade lip than at present. I have made 
attempts, as in Case 177, in which the tissue of the new lip was very thick 
under the nose, and gradually became thinner as the red border of the lip 
was approached, to roll down the flap of subcutaneous tissue from the upper 
and nasal aspect of the lip to the free border. This partially succeeded. It 
may be that very thin strips of cartilage inserted under the skin might produce 
a satisfactory edge to a lip as well as a filtrum. 

In regard to the provision of the mucous membrane, this is a matter 
which requires very close examination in each case, for frequently a good deal 
of useful mucous membrane has been saved after the injury. Frequently 
small flaps of skin in the neighbourhood can be turned, with . their skin 
surfaces inwards, to keep the lip free, and, in addition, the ascending flap 
mentioned above, which not only contains skin and muscle as well, can be 
made to include mucous membrane. In such a case the whole new upper 
lip is made with one design. Personally, I have not used this flap on many 
occasions, either because it was not necessary, or because some complicating 
scars were present. The only disadvantage of taking the mucous membrane 
with this ascending flap is a certain amount of shortening of the cheek 
mucous membrane, and if there is any septic process occurring after the 
operation, one is liable to create adhesions in one or other sulcus affecting 
the efficiency of mastication; but, with a well-cut flap and proper attention, I 
do not think this complication should occur. 

Another method of providing mucous membrane for a vermilion border 
of the new upper lip is one involving the transference, in two stages, of the 
mucous membrane flap from the lower lip. 

If the vermilion border missing is situate on the outer third of the lip, then 
the mucous membrane flap from the lower will have its base near the corner of 
the mouth. But if the missing portion of the vermilion border is in the central 
portion of the upper lip, a flap is conveniently turned up, in a vertical direction, 
from the centre of the lower lip, with its base towards the free margin of the 

In this latter event, it is necessary to stitch the two lips together while 
union is taking place and before the pedicle is divided. For the details of such 
operation see Case 184, p. 150, 


A few other general points about upper lips are worthy of mention. Com- 
plete loss of the upper lip does not occur, in my experience, without the loss 
of the pre-maxilla, and quite half the difficulty of forming a satisfactory upper 
lip in a complete loss is to be found in the difficulty of restoring the bony contour 
by means of a dental appliance. There are usually very few teeth left in the 
upper jaw on which to carry a satisfactory prosthesis ; in addition, one fre- 
quently makes a mistake in making an upper lip with flaps insufficiently long, 
and consequently there is a tightening and flatness, and the denture becomes 
very liable to be pressed on and easily displaced. Another of the mistakes 
that I have perforce fallen into is that one did not at first realise that the 
prominence of the central portion of the upper lip was due not entirely to the 
pre-maxilla, but to what I describe as the suspension of the upper lip from 
the columella of the nose. The upper lip hangs like a curtain from the 
columella. With one's fingers in the vestibules of the nose, gripping the 
columella, one finds that the upper lip is suspended by that portion of the nose. 
Looking at a normal upper lip from the side, one is aware that it runs well up 
into the columella, whereas in actual practice the majority of the new upper 
lips do not present this suspension from and incorporation into the nose ; 
they seem to run straight across from one ala to the other in an abnormal 
manner. Frequently, of course, this condition results from the accom- 
panying loss of the columella and anterior nasal spine ; but, in repairing 
the upper lip, the anatomical attachments that I have mentioned should be 
aimed at. 

I am indebted to Professor Henry Tonks for pointing out to me the defects 
in the upper lip from this point of view, especially from the loss of the pre- 
maxillary prominence, and, on thinking the matter over, the suspension of 
the upper lip from the columella presented itself to me. 

It is quite reasonable, as mentioned above, to turn a portion of the lower 
lip into the upper; but when this process is overdone, the result is most 
unpleasant. The greatest care must be exercised in this manoeuvre to see 
that ugly deformity of the angle of the mouth is not produced. 

In comparing it with the lower lip repair, it would seem to me that 
the shortening of the upper lip is a very much greater defect than a similar 
shortening of the lower. In a few words, it is quite possible to sew up a lower 
lip which has lost nearly a third of its bulk without causing either a serious 
functional or aesthetic deformity, whereas a similar loss of the upper lip cannot 
be produced without very serious impairment of function, accompanied by 
a most unpleasant effect, and it is probably for this reason that, in my 
experience, the formation of the upper lip is more difficult than that of the 



Those that I have chosen to demonstrate loss of the upper lip and its repair 
have been grouped in the order of decreasing severity ; thus the first few are 
examples of complete loss, whereas the last are of minor injury of the lip. 

Total loss of the upper lip, as I have already stated, is not met with without 
the accompanying loss of the pre-maxilla, either in part or as a whole. Fre- 
quently these severe injuries of the upper lip involve the lower portion of the 
nose, and in some cases the whole of the nose, as well as the pre-maxillary 
and central two-thirds of the upper lip, has been destroyed by one projectile. 

The problem of the repair is to a large extent dependent on this loss 
of the pre-maxilla. I have divided the severe upper lip injuries into those 
accompanied and those unaccompanied by loss of the bony structure. It 
is with the bony loss type of lip that the aid of the dental surgeon must be 
urgently invoked. In all cases a prosthesis should be prepared, which will 
ensure that the new lip is efficiently supported from underneath, and at the 
same time that the incisions of the mucous membrane do not lead to cicatricial 
contraction of the upper sulcus. It should be designed so as to have as perfect 
a fit as possible, and, if necessary, it may be supported from the lower teeth 
or even from a lower denture. This dental appliance must be so made as 
to ensure that the new lip is of sufficient size. After the under-lining of the 
new lip is satisfactorily made of mucous membrane or skin turned inwards, 
very little if any contraction need be allowed for, but if any raw areas on 
the under-surfaces of the lip are exposed to the buccal secretions, ulceration 
will cause severe contraction. No upper lip should, therefore, be designed 
which does not include its most important element, the mucous lining. In this 
class of case, the following is a good example : 


CASE 106 

This R.A.M.C. Orderly was wounded by a shell fragment on 28.4.16, and 
admitted for plastic treatment on 27.6.16, two months after he actually received 
his injury. His condition was most repulsive complete loss of the upper lip was 
accompanied by total loss of the pre-maxilla and by destruction of the anterior 
portion of the floor of the nose, and of the adjacent walls of left antrum. The nose 
was considerably deformed and dragged downwards in the healing process. A 
satisfactory dental appliance having been made by Captain L. A. B. King, L.D.S., 
and his staff, the patient was operated upon under general anaesthesia. 

Preliminary laryngotomy was performed by the Butlin method and the anaesthetic 
given through this opening. The pharynx was packed off so that blood did not 
enter the lower air passage. The main design of the operation is shown in diagram 107, 
which needs little amplification. The main part of the upper lip was made by a 
descending lateral nasal flap which was swung from the right side across to the left. 
This flap included muscle and mucous membrane, and, in order to lengthen it, the 
knife was carried through the corner of the mouth in a parallel direction to the first 
cut. This flap reached about two-thirds of the way across the lip. On the left side, 
the broad flap, as shown in the diagram, was outlined and swung up to meet its 
fellow. This flap was broader at its base than at its extremity ; it also included 
mucous membrane. In regard to the nose, the left ala, which was tied down to the 
remains of the nasal floor, was elevated, and re-sutured into position. On the whole 
the result of this operation was fairly satisfactory; the mouth, however, was small 
and the upper lip did not present very good lines, nor did the muco-cutaneous 
junctions show at all as a vermilion border. The manoeuvre of pulling over the right 
flap towards the left had narrowed the mouth. Subsequent correcting operations 
were performed on various dates. Under a local anaesthesia, the right corner of the 
mouth was enlarged by a simple incision and the pulling out of the mucous mem- 
brane. On 16.1.17 examination notes read that deep scars were radiating from the 
left angle of the mouth into the lower lip, while other scars were present at the 
junction of the flaps making the new upper lip, and in the left cheek. All these scars 
were more pronounced than usual. Under general anaesthesia, they were dissected out 
that in the upper lip was dissected out in a diamond-shaped fashion, there being 
a slight notch at this point, and sewn up vertically to give extra depth. This 
manoeuvre was quite satisfactory, but not quite sufficiently radical. The notch in the 
lower lip was rearranged by swinging flaps, as shown in fig. 110. A small excision 
was carried out just above the right angle of the mouth to raise the same, while the 
ala of the left nostril was carried farther to the left. All sutures were carefully made 
with interrupted horsehair. The results of these corrections were satisfactory on the 
whole, except that the scar lines were still very prominent. Three months later, 
17.4.17, the mucous membrane of the upper lip was brought farther out to become 
more prominent, and one of the scars of the lower lip was re-excised and sewn up 
with subcutaneous catgut. The scar-line thus produced was again unsatisfactory, and 
it was apparent that this man's skin, though it always united well by primary union, 
was of an unusual character. The reason may be forthcoming in the fact that there 
is a considerable amount of acne present. The later history of these scars is inter- 
esting, as they are apparently becoming more obliterated than usual by tiny bridges 
of skin growing across, and already one of the scars is invisible. 

This case has opened up the question of the histology of good scar production. 

The two small palatal perforations were closed by mucous membrane flaps on 
7.6.17; one of the flaps partially broke down. In order to fill up the depression 
in the left cheek, the lateral scar, shown in fig. 1C 9, was excised, and the skin under- 
cut in its neighbourhood and free fat-graft from the subcutaneous tissue of the 
abdominal wall inserted; the skin was sewn up with subcutaneous horsehair. 

Like many other fat-graft operations in this region, the union was primary and it 



was not until a week after the stitches were out that a slight oozing of fat occurred 
followed by some suppuration. This condition was cleared up with Biers' cupping, and 
th.3 final result is satisfactory. Even after the first operation, it was a great satisfaction 
to hear this man speak with his native brogue again. Before operation he was a man 
who was so sensitive about his appearance that he did not like mixing with his fellow 
patients or with the outside public. 

Fio. 105. On admission. 

FIG. 100. Prosthesis in position. (Discoloration 
due to Iodine.) 

Fio. 107. The (laps. Right, descending. Left, ascending. 

Fio. 108. Suture. 



Fid. 109. First result. 

Fio. 110. Upper and lower lip corrections. 

Fio. 111. Suture. 

FIG. 112. Final. 



CASE 525 

An example of total loss of upper lip. This man on admission to a Base hospital in 
France still possessed an upper lip, but it was in a damaged and semi-gangrenous condition, 
and, in spite of the utmost care, the whole thing sloughed, leaving the condition shown in 
fig. 113. Partial attempt to relieve the deformity had been made prior to admission to my 
service, the result of which procedure is shown in fig. 114. The mouth is very contracted 
and the lower lip pouted. The new upper lip is insufficient and short, while the whole nose 
is lengthened and depressed. It was decided to reconstruct the wound and to replace 
the nose in its normal position. 

Operation, 23.7.18. Scar tissue in the centre of the new upper lip was excised, as was 
that around the attachment of the nose. The stumps of the upper lip were allowed to 
retract into their normal position, in which situation the mucous membrane was brought 
out and sewn to the skin. No attempt was made to repair the lip at this stage. The nose 
was gradually freed until it could be raised into its position. The only blood supply re- 
maining to the nose being a small bridge in its upper part, this undercutting and raising had 
to be done with the greatest of patience and care. The alae were brought together beneath 
the tip and the nose sutured. This was a very risky procedure, and I was more than thankful 
for its satisfactory result. 

It now remained to repair the upper lip uncomplicated by the false attachment of the 
nose. Elaborate diagrams by Mr. Hornswick of this operation are included, and show the 
developments of diagrammatic illustration for this form of record in an exceedingly difficult 

Haps A and B from the left and right cheeks respectively were turned skin-surface 
inwards over a large dental appliance fitted by Captain W. Kelsey Fry, M.C., R.A.M.C. ; 
they were sutured together. The mucous membrane off the stumps of the upper lip was 
cut into two flaps (C and D), one on each side, and by advancement came to lie along the 
lower borders of A and B, where they were sutured, not only to each other, but also to A 
and B. These mucous membrane flaps were broad enough to complete the lower border 
and to curl round for the vermilion edge of the new lip. 

FIG. 113. 

Fid. 114. 

FIG. 115. 

FIG. 113. Total loss of upper lip and underlying bone. (Photo taken in France.) 

FIGS. 1 14, 1 15. Condition on admission. These show the indifferent result of making a lip by advancement 
methods. Both the lips and the nose are backwardly displaced. The mouth is contracted, and the lower lip is 
pouted. [Note : These defects have, in this case, been accentuated by the failure of part of the flaps to survive.] 



The skin covering was the next problem, and 
double ascending flaps A' B' were taken from the 
lateral aspects of the chin and sutured together over 
the inturned flaps A and B. To their lower borders 
were sutured the lower free borders of the mucous 
membrane flaps C and D. 

The secondary closure did not present any great 
difficulties. The most anxious part of the operation 
was flap A', which had a great deal of scar tissue in 
it. In fact, the only clear bit of skin was a minute 
portion on its lower border. I had great fears of 
losing the whole flap. However, the blood supply 
returned and was maintained satisfactorily. Apart 
from some slight breaking down of the suture line 
A' B', the healing process was satisfactory. The 
columella had been brought out, lengthened and 
sutured in the middle of the upper lip : this wants 
rearrangement, as is evidenced from the photograph 
which merely represents the present stage of the 

Fio. 116. Diagram of the ex- 
cision of scar tissue, practised 
to bring about replacement of 
the nose upwards and forwards, 
and to allow the corners of the 
mouth to separate. 

Fio. 117. Fio. 118. 

l'io. 117. Shows the result of putting into practice the author's principle of replacing the remnants into 
normal position. Skin is sewn to mucous membrane so that no raw area occurs. An upper prosthesis is now 
fitted, replacing the lost hard tissues. 

Fio. 118. Profile of same stage, showing the vast improvement in the nose. No apparatus was employed 
to retain the nose. 

FIG. 1 1 9. The incisions. 

Fio. 120. The flaps. 

Fio. 121. Suture of the interned 
and mucous flaps. 

Fio. 122. Final suture. Fio. 123. Sectional view. 

FIGS. 119123. A and B = cheek flaps, inverted to form the posterior epithelial surface of the new lip. 

C and D = mucous membrane, advanced flaps taken from the lip stumps to form the mucous membrane 
lower border of the new lip. 

A' and B' = ascending cheek-chin flaps to form the outside skin covering to the whole. The raw areas caused 
by the cutting of these two flaps is closed by approximation. 

FIG. 124. 

Fid. 125. 

Fio. 124. Result of the six-flap plastic operation portrayed in the diagrams. A permanent upper prosthesis 
; fitted. 

FIG. 125. Profile of result. Note the pi 
apparatus representing the missing maxilla. 

S FIG 125. Profile of result. Note the prominence of the new upper lip, which is supported by a vulcanite 




In the next case also one of similar but less destruction of upper lip the prc-maxilla 
was destroyed ; but a small and valuable piece of upper lip remained at the left angle (a 
point not evident in fig. 126, taken a fortnight after the wound). Fig. 127 shows the healed 
condition, a remarkable improvement. The lower lip has become almost normal, and 
little scarring has resulted, but the remains of the left upper lip have become attached 
and drawn upwards. 

Primary suture was expressly avoided, and the main repair of the upper lip^was per- 
formed over an effective dental support ten weeks after the wound. Lateral nasal flaps 
were used on both sides (fig. 128), and by advancement of the mucosa of the left side, it 
was made to cover half the under aspect of the new lip, and to line not only the left but 

FIG. 120. On admission twelve days after injury. 

Fio. 127. The healed condition. 

part of the right side. Ihe lining was completed by advancing a descending flap of mucous 
membrane from the right cheek near the angle of the mouth. The result is shown in fig. 130. 

A month later, a more extensive operation was made, to level the mouth and to adjust 
the relation of mouth to nose : the lower nose was freed from bone, and swung to the right. 
and the upper lip to the left, both being sutured in their new position. Though the nose 
pointed somewhat rightward, yet, viewed with the mouth, it gives a more symmetrical face. 

A right chin flap was then swung up to the upper lip, to deepen it, and was lined by 
an advancement of mucosa. As usual, this flap depressed the angle of the mouth slightly, 
a defect not hard to overcome. 

An effort was first made to raise the angle by a horizontal incision through all thick- 
nesses of the lip opposite the seat of the depression, sewn up vertically. This resulted 
in a partial improvement of the deformity, and is a method not often indicated. Two and 
a half months' rest was given, during which massage and movements were undertaken. 
The diagram, fig. 13, shows the method of curing the depression of the angle of the mouth, 
and is in reality a partial replacement of the original flap. A satisfactory result of this is 
shown in the final photograph. All scars were fading rapidly when the patient was dis- 
charged, and the total eflect was gratifying. 



Fio. 128. Incisions. Fid. 129. Suture. 

The clotted area represents a mucous membrane flap. 

Fid. 130. First result. 

FIG. 131. Shows method of curing a depressed angle 
of mouth. Xote: this condition had occurred owing to 
an operation referred to in the text but not illustrated. 

Flo. 132. Final result. 


CASE 21 

This case is one of a very similar character to the last, and about the same amount 
of the upper lip remained after the injury. The denture fitted to represent the pre-maxilla 
is shown in the accompanying figure, No. 133. This case, treated on similar lines to 
No. 17, has not shown the same satisfactory results. The lip was made too short, and 
considerable difficulties were experienced in fitting a satisfactory denture after the new 
lip had been made. The probable reason why this case has not done so well as the 
previous one is that there was less mucous membrane remaining after the injury. 
Trouble was also experienced in retaining the denture, and adhesions formed between 
the new lip and the remains of the upper jaw. There were also adhesions to contend with 
between the cheek and the lower jaw, which made the dental treatment more difficult. 
In this case it would have been wiser to use a skin flap, turned inwards, to line the new 
lip. It will be noted that an ascending flap was not available on the right side on 
account of the scar tissue there. A modified descending flap was therefore used on both 
sides, and that on the right had a bend in it which turned it in to an advancing flap. 
The patient had erysipelas about six weeks after receiving his wound. The first 
operation was undertaken about three months after the date of his injury. This was 
performed on 9.10.16, when adhesions tying down the nose were divided and scar tissue 
excised ; about in. of the red margin on the left side was intact. A flap, including this 
portion of the lip as its base, was cut from the left side of the nose and brought down 
under the nose. A skin and tissue flap from the right side, with its base opposite the 
mouth, was cut and straightened out to meet the corresponding flap from the other side. 
A mucous flap from the inside of the right cheek was cut with its base on the lower lip and 
curled around part of the new upper lip. A hare-lip condition was thus left, but it was 
not deemed advisable to form a double mucous flap. No relaxation sutures were used, 
but several silk-worm-gut deep stitches were inserted. There appears to be some tension. 

Fio. 133. Denture with artificial pre-maxilla. 

Examination of the condition after this operation showed that the new mucous lining 
to right half of upper lip was satisfactory. There was a U-shaped gap in the middle of 
the upper lip, and no columella. On 2.11.16 an excision of the scar was made round 
the U, and prolongation of the incisions laterally on the left through the angle of the mouth 
and through the line \ in. above it, and through all the layers of the lip ; this was brought 
over to the right and sutured into position with catgut and horsehair sutures. The 
columella of the nose was formed by cutting out the anterior portion of the remains of 
the septum ; in this upper part the knife was entered behind and brought forward towards 
the tip, and this made a satisfactory columella, which was inserted into the incision of the 
upper lip. In spite of careful suturing the left angle of the mouth drooped. Adhesions 
were divided between the lower jaw and mucous membrane on the right " side. The 
attachmsnt of the new columella broke down, but otherwise the results are fairly satis- 



factory. Great difficulties were experienced in keeping the lip well supported with the 
denture, and adhesions reformed. I think the flap on the right in the original operation 
should have been taken right through to the mucous membrane instead of making two 
flaps, one of skin and muscle and one of mucous membrane. The appearance after these 

Fia. 1 34. On admission two months after 

FIG. 135. Healed. The dental appliance 
displaced to show its composition. Note 
the scar on right cheek referred to in text. 

FIQ. 130. Flaps. (A mucous membrane flap not outlined.) 

Diagrams by H. T. 

Fio. 137. Suture. 


FIG. 138. Result first two operations. 
Note droop of angle : denture not in place. 

FIG. 139. Flap to raise angle. 

FIG. 140. Suture. 

FIG. 141. Result of this. Denture fitted. 



two operations is shown in the accompanying fig. 138. The falling in of the lip without 
the denture and the droop of the left corner of the mouth is well seen. A small operation 
was performed on 13.3.17 in order to raise the corner of the mouth, and this was 
successful in carrying out this object. In order to fit the denture in, Captain Rumsey 
divided the upper sulcus. 

Scar tissue formation, however, gradually filled up this sulcus, and prevented the 
further wearing of the denture. In addition, trismus was present, which, on investigation, 
was found to be due to a band of scar tissue from upper to lower jaw on the right side 
of the cheek, and which had formed as a result (a) of the injury, and (b) of the intra-oral 

On 9.1 .18 an operation to remedy these defects was undertaken, the principle being 
that of the Esser epithelial inlay. 

To repair the upper sulcus, an incision was made at the upper border of the upper 
lip and carried down to the mucous surface. Care was taken to excise a portion of the 
scar band above mentioned. The cavity produced was of some size, and extended from 
just to the right of the scar band to where the sulcus became normal again on the left 
side of the mouth. The usual Stent model and skin graft was inserted. 

A similar procedure was carried out along the lower sulcus. The models were taken 
out on the tenth day through intra-buccal incisions. 

Considerable difficulty was experienced in keeping the newly epithelialised cavities 
patent, and, as the upper sulcus was the more important of the two, it received more 
attention. The successful establishment of this sulcus was to a great extent due to the 
careful efforts of Captain Kelsey Fry, M.C., R.A.M.C. The lower sulcus operation was 
not so successful. It would have been better to have done this at a separate operation. 

The upper lip is now maintained in a forward position. 

On 4.6.18 the columella was re-made in a manner similar to the first procedure 
but of a greater length, so that the tip of the nose was even .pushed up a little bit by this 
new columella. 

FIG. 142. 

Final after Esser inlays and columella operation. 



CASE 151 

This is one of the Australian patients who have been under my care. He was wounded 
in the later battle of the Somme, and came to me at Aldershot, six days after receiving 
his wound on 20.10.16. 

The condition, when healed, showed a considerable loss of the pre-maxilla, and the 
floor of the nose in its anterior part, while the soft tissue loss consisted of about two-thirds 
of the upper lip, together with the left ala, columella, and anterior portion of the septum 
of the nose. The tip of the nose was dragged down by fibrous tissue and loss of support. 

The first operation was undertaken on March 3rd, 1917. It was of an orthodox 
type, and consisted of two lateral nasal descending flaps, A B and A B. These were 
whole-thickness flaps which contained the mucous membrane. That on the left proved 
to be satisfactory as it contained the remaining normal part of the upper lip, but that 
on the right contained much scar tissue, and the result was not gratifying. 

Diagrams representing the next stage are appended, and the details of this operation 
follow : 

The main principles of it were, in regard to the nose, that two higher lateral nasal 
flaps were tucked in beneath the alse to allow the tip of the nose to rise. And in regard 
to the right half of the lip, it was deepened and reconstituted by turning downwards a 
flap of skin as a lining and the superimposition of a long pedicled bridge flap from the 
left cheek and chin. 

When this case was transferred under Lieutenant-Colonel Newland, D.S.O., A.A.M.C., 
he very kindly allowed me to continue the treatment, and I have had the encourage- 
ment of his advice and assistance in this somewhat long and difficult procedure. The 
case is not yet completed, but is well in hand, and the final result should repay one for 
the efforts and length of time expended on the case. 

FlO. 144. Six days after wound. 

FIG. 145, When healed. 

FIG. J4G. Side view. 
Same stage. 



Copy of Case Sheet Notes given below : 

10.3.17. Operation. An upper lip was formed by cutting a flap from right cheek 
and swinging it down to meet a similar one from the left ; but this latter contained normal 
mucous membrane. 

FIG. 147. Showing descending flaps. 

Fia. 148. Suture. 

Fio. 149. Result of lirst operation. 

The tip of the nose was freed and nasal 
passages restored. Tissue representing remains 
of columella was dissected up and sutured to 
middle line of lip. Small mucous flap was 
turned up from lower lip to form red line for 
remainder of upper lip. Deep catgut sutures 
were used, and artificial plate was inserted 
to support new lip. Nasal plugs, supported 
by vulcanite head piece, were adjusted with the 
object of holding tip of the nose in position. 

20.9.17. Condition. Previous operation 
for upper lip moderately successful. Con- 
siderable deficiency middle of right half of 
upper lip. Deformity of nose partially cor- 
rected, but columella has not become attached. 

20.9.17. Operation. For correction of 
upper lip. Owing to the scarred and pustular 
condition of the face, no flap was available 
from the right for the lip. In order further to 
raise the right ala, a small flap was taken 
from the lateral aspect of the nose and swung 
down beneath the ala. A similar flap was 
swung down on left side beneath the remains 
of the left ala and sutured to the top of the 
upper lip. This enabled the tip of the nose to 
be considerably raised. 



A skin-flap of the existing right portion of the upper lip was turned downwards, 
with its skin surface inwards, and into this raw area was laid the end of an ascending 
pedicle bridge flap with its base opposite the upper lip on the left side. The area from 
which this flap was taken was completely sewn up. The grafted end of this flap obtained 
linn union into the upper lip and the pedicle of the flap was cut under local amrsthetic on 
October 13th. No attempt at replacing the pedicle was made, and it was cut short at its 
base. This free lump of skin was left sticking out from the lip for possible future use in 
the nose. Massage was employed from the first day. 

24.10.17. Condition satisfactory. It is possible to train this flap of skin upwards 
towards the nose for later attachment there. 

Operation (Major Gillies with Lieutenant-Colonel Ncwland). The cut pedicle 
referred to above had rounded itself off into what looked like a tip of a nose lying on the 

FIG. 1 50. 1 ncision for inverting portion of lip to 
complete the lining 

FIG. 151. Diagram showing bridge pedicle flap A. 
Terminal portion only used. 

upper lip. It was partially re-detached, and sewn up underneath the columella and left 
ala. Lip support was made by Captain Russell, A.D.C. 

4.2.18. Operation (Major Gillies with Lieutenant-Colonel Newland). Further de- 
tachment from lip and completion of right half of columella. 

16.5.18. Operation (Major Gillies with Lieutenant-Colonel Newland). The left side 
of columella and lining of nostril was made, and the remainder of flap was used to form 
the left ala. 

20.12.18. Operation (Major Gillies). Cartilage taken from rib and inserted through 
the columella in two pieces, one down the columella and one up the bridge. The bridge 
piece was fixed at its upper end to the existing nasal cartilage through a separate incision 
made across the bridge at a spot where an existing scar was present. Result satisfactory. 
Hut owing to the pustular condition of the face, which has continued despite special treat- 
ment, a slight infection of the cartilage occurred. No material damage, however, eventuated, 
and the sinus rapidly healed. 



FIG. 152. The pedicle cut near the base and 
allowed to curl up. 

FIG. 153. Utilising the pedicle for nasal 

FIG. 154. Result after further adjustment and 
cartilage implant to nose and columella. 

FIG. 155. Ditto, side view. 



CASE 245 

This sergeant was admitted in a healed condition. There was partial loss of the 
pre-maxilla, and loss of more than half of the upper lip, together with an iigly twisting 
of the nose, and depression of the tip. This patient was operated on four months after 
the receipt of his wound. It will be noticed in the appended operation notes that he 
developed bronchitis after the operation. Therefore the failure to get a really satis- 
factory result may well be put down to this trouble, as the coughing which followed 
undoubtedly prejudiced the union of the flaps. Three weeks after this operation the 
patient, when at a Convalescent Hospital, developed septic pncuziionia, from which he 
recovered slowly. 

Although the record number is a late one, this was one of my early cases, and it brought 
home to me the necessity for some different form of anaesthesia from that usually employed 
in mouth cases, and in those of chin and upper lip in particular. In the pages on 
anaesthesia this matter is fully dealt with. A fairly satisfactory result was obtained 
from an aesthetic point of view, and, functionally, it was good. It should be remarked, 

FIG. 150. Condition on admission healed. 
Loss o right half of lip. 

however, that a secondary deformity of the lower lip was produced. Since the date on 
which the last illustration, fig. 161, was taken, this sergeant has done a year's duty witli 
Home troops. Details of operations on this case follow : 

22.6.16. Operation. Formation of upper lip. The flap of skin and mucous mem- 
brane representing the remains of the upper lip was dissected out from left nostril, and 
by an incision parallel to the lip margin the flap was brought over towards the right to 
meet two flaps from the right side which were separated by a piece of excised scar. The 
lower of these flaps was a small one, containing the angle of the mouth. Result : The 
dental shield for the new lip which had been made was not tolerated by the patient, who 
had some bronchitis after the operation. A certain amount of breaking down occurred 
at the junction, and owing to the absence of intra-oral apparatus the new lip became 
adherent to the alveolus of the upper jaw. Apparatus for distending of lip after division 



of adhesions is shown in photograph. Three minor operations were carried out to widen 
the mouth and to produce a mucous membrane line to the upper lip. Functionally the 
result was good, cosmctically there was still an ugly arrangement of the lower lip. Dis- 
charged for duty, 3.3.17. 

FIG. 157. Advancing flaps. 

FIG. 1 58. Result, flat lip. 

FIG. 159. Suture. 

FIG. 100. Attempt to bring forward and stretch 
new lip. 

FIG. 161. Result of later operations. Denture 
fitted. Note : the lip is still flat and has no 
central prominence. The lower lip is pouting. 



CASE 4.3 

These cases of upper lip arc dealt with here in order of decreasing severity, and this 
one shows a loss which is less than the previous one. The result is correspondingly better. 
In addition to an upper lip injury, there was a slight deformity of the lower, combined 
with loss of the angle. The condition within forty-eight hours of the wound is shown in 
the first illustration, and I am indebted to Major Valadier, C.M.G., for allowing me 
to have the early wound record of this case. The second photograph is an illustration of 
the result of an early suture, performed by Major Valadier in France. The mucous mem- 
brane of the upper lip was preserved by sewing it to the chin, and the tag on the cheek 
was sutured into place, the mucous membrane being also brought out to the skin edge. 
This system undoubtedly helps the later plastic repair as it decreases the scar tissue. 
Accompanying this injury was a very large loss of bone in the lower jaw, involving the 
angle and adjacent portions of the mandible ; there was also a considerable loss of bone 
in the superior maxilla and alveolar process. The further method of repair is illustrated 
in the accompanying diagrams, and consisted in a whole thickness flap swung down from 
the left lateral nasal region to meet the remains of the upper lip which was split to 
receive it, the lower portion of the split containing the vermilion border being made to 
extend along the new portion of lip. 

To complete the mucous membrane, that of the lower lip was swung round the corner 
to the upper, a slight advancing of the flap marked " B " enabled the lower lip to be satis- 
factorily corrected. No further operations on the lip were undertaken, and a satisfactoiy 
result was produced. Discharged to duty. 

Kio. 162. Shortly after wound. Taken in France (Valadier). 



FIG. 163. On admission healed. 

Fio. 104. Descending and ascending whols 
thickness flaps. 

FIG. 105. Suture. 

Fia. 100. Result. 

Fio. 107. Same later. 



FIG. 108. Prior to admission to Queen's Hospital. 

FIG. 109. On admission healed. Part loss of 
upper lip, nose, and cheek. 

CASE 324 

This is included in this series as an example of the use of a temporal and scalp flap for 
the external covering of a portion of the upper lip. One half of the upper lip remained on 
the left side, the right half being completely absent, as well as a large portion of the cheek, 
nose, and right superior maxilla ; there was an accompanying fracture of the right mandible, 

FlO. 170. A and B are interned epithelial FIG. 171. E the temporal flap 

fla P 8 - sutured to form the covering. Fl(J , - 2 _ Result after return of temporal 

flap. Note deficiency of upper lip, and of 



with deformity of contour. The patient was transferred to this hospital eleven months after 
being wounded. The mandible had united by approximation. The first operation was 
undertaken as a combined lip, nose, and cheek plastic. In fig. 170, flaps A and B were 
turned skin-surface inwards to form a lining for the right ala and right half of the upper 
lip. The latter was sutured to the mucous membrane on the back of B, which is the re- 
maining portion of the upper lip. Over the raw area thus produced a shaped flap, E, from 
the right temporal region was sutured into position on 24.9.17. Three weeks later the 
pedicle of flap E was returned. This was done for me by Captain C. F. Rumsey, R.A.M.C., 
and the result of these two operations is shown in the next fig. 172. Considerable time was 
allowed to elapse during which cpilation by X-rays of the hairy surface of the nose was 
undertaken. As the new upper lip was too shallow, it was decided to turn skin surface 
inwards a portion of this new flap and to bring up an ascending flap from the right side 
of the chin, and at the same time a flap of mucous membrane was brought up from the 
lower lip for a vermilion border. 

Rhinoplasty was performed on 18.11. 18, and at this operation the pedicle of the mucous 
membrane flap of the previous operation was divided to form the right corner of the mouth. 
When the pedicle of the rhinoplasty was returned a depressed scar, caused by the ascending 
lip-flap, was excised, and a notch in the new upper lip was corrected by a Rose operation 
(Captain Ferris N. Smith, R.A.M.C.). Cartilage was inserted over the right mandible and 
further scars excised on 3.2.19. Present result is shown. 

Fro. 173. 1. Deepening the lip by an ascend- 
ing chin flap. 

2. Mucous membrane flap from lower to upper 

3. Preliminary to radical nasal reconstruction. 

FIG. 174. Final result of lip, cheek, and nose 
plastics. Note the improved cheek contour by 
cartilage graft. 



CASE 143 

There arc several interesting features about this case which need defining. I have 
included it in the " Upper Lips," as I have learned a principle in connection with its repair. 
It is also one of my first cases. I designed the upper lip operation with two superimposed 
flaps so as to produce depth at the spot where the hare-lip type of notch was present. 
Tin- two flaps were made to overlap after the replacement of the vermilion border to 
its normal level. A good deal was allowed for contraction, and the right-hand flap was 
cut in such a \\ay as to produce considerable drooping of the right half of the upper lip. 

Fio. 1 75. Hnre-lip type of deformity with 
loss of substance. 

FIG. 1 70. Scar excision. 

Fio. 177. Scheme of the flaps. 

FIG. 1 "8. Diagram of 
overlapping flaps to pro- 
duce depth. 

FIG. 179. Result of Jip operation. Xote 



There was no important loss of the mucous membrane lining of the upper lip, and 
consequently the retraction and contraction following the operation was very limited. 
Therefore I had to excise portions of this flap until the correct level of the vermilion 
border was obtained. Another principle involved in this repair was to use pointed 
overlapping flaps to produce depth. 

In regard to the nose plastic, the scar running down the right aspect of the nose and 
across the bridge was excised ; the nose was raised and the right ala was sewn down at a 
lower and normal level. This was done on the occasion of the second operation. A month 
later a bone graft was taken from the left tibia and inserted into the bridge of the nose to 
raise it. The bone was cut with the Albce double electric saw. The periosteum was not 
included. In regard to the fixation, the periosteum over the glabella region was raised 
and a groove made into the bone into which the upper end of the graft was fixed. The 
distal end of the graft was pushed down subcutaneously into a cavity made for it nearly 
as far as the tip of the nose. A misfortune occurred 
at the end of this operation, as the patient vomited 
freely before the graft was quite fixed in position 
and the asepsis of the field of operation was thereby 
violated. A slight suppuration followed, but this 
practically cleared up except for an occasional drop 
of pus which could be squeezed out. Later a small 
portion necrosed and was taken away from near the 
left internal canthus. The skin then healed up 
satisfactorily, but no bony union occurred with the 
frontal bone. When last examined, the graft was 
still in position, but is presumably in process of 
being replaced by fibrous tissue, and the bridge had 
not been sufficiently raised. It was decided, there- 
fore, to insert some cartilage, which was done 
through an incision over the tip of the nose and 
into the columella. A piece of costal cartilage 
was then superimposed over the remains of the 
bone graft. When in position, the extremity of the 
cartilage was bent into the tissues of the columella 
to support the tip. The incision over the bridge 
of the nose was likewise reopened at this operation, 
and an attempt was made to get union with the 
frontal bone by turning down an osteo-periostal 
flap beneath the original bone graft. Whether 
bony union occurred or not was not established as 
the patient was discharged to duty, but the cartilage operation was satisfactory in every 
way except at the bridge of the nose, where it became slightly displaced. As far as the 
left eyelids are concerned, mal-union of the upper lid had occurred, completely obliterating 
the palpebral fissure. This upper lid was freed by a mesial descending incision, and the 
lid was sewn up at a higher level. The lower lid was also freed by carrying a curved 
incision from the inner angle outwards beneath the lower lid, and this also was sewn at a 
higher and more mesial position. A moderate amount of vision remained in the left 
eye, and considerable benefit accrued to the patient by reopening his palpebral fissure 
both in regard to appearance and function. The final result is shown in fig. ISO. 1 

FIG. 1 80. Excision of excess lip and nose and 
eyelid plastics. 

1 This is the only case in which I have used bone alone for raising the bridge of the nose. Compare 
this case with case 252, p. 228. 


CASE 48 

Another type of upper lip is shown in the following case. The patient was received 
after many plastic operations in the condition shown in fig. 181, and there was a large muss 
of scar tissue making up the substance of the upper lip. There was a blob of mucous 
membrane at the left corner, which was utilised by extending it along to the right. The 
patient was edentulous. This also was one of my early cases. The result of the first 
operation is shown in the second picture. The main feature of this operation was the 
excision of the scar which was present in the upper lip and around the depressed angle of 
the mouth. This left a very large gap to be filled in, which difficulty was met by a descend- 
ing flap from the left cheek. The flap united satisfactorily in its new position, but the 
suture of the cheek after the removal of the flap broke down somewhat badly, as is evident 
in the photograph. A subsequent operation was performed to widen the mouth, but this 
had to be curtailed owing to anaesthetic difficulties and blood collecting in the patient's 
throat. The scar of the face was excised, but again this broke down. I decided, therefore, 
to give him a prolonged course of X-ray treatment, massage and special vaccine made 
from culture of his own micro-organisms. An attempt was again made to excise the ugly 
scar on the left cheek; but, as on previous occasions, this broke down, but only partially. 
The total result was a very considerable improvement in appearance and function. 



FIG. 181. Large portion of upper lip occupied by 
keloidal scar. 

FIG. 182. Note breaking down of secondary 
suture area, after the descending lateral nasal flap 
had been brought down to upper lip. 

Fio. 183. Final result. 


CASE 242 

This case shows an injury of the lip without serious bony damage, with less of teetli 
only. The loss of the lip is a little more than a third, but the loss of the skin surface is 
greater than that of the mucous membrane. The condition when it had healed is shown 
in the next illustration, which, however, does not adequately represent the amount of scar 
tissue to be excised. The morphology of the original wound was therefore reproduced, 
but to a slightly diminished extent. The diagram illustrates the amount of scar tissue 
which had to be excised and the flaps used to repair it. It should be remarked that 
the vermilion border b?longing to the right-hand flap was separated from this flap and 
advanced on to the lower border of the left-hand flap, so that the skin-joint was not at 
the same site as that of the mucous membrane. In criticising the result of this procedure, 
which was, in general terms, a descending flap and partly an advancement method, it 
will be observed that the upper lip slightly overhangs the lower at the left-hand corner 
of the mouth, and the lower lip is somewhat pushed out of position thereby. This, I 
think, is due to the advancement of the flap, and bears out my contention that the 
upper lip will stand little in the way of shortening by advancement flaps. 



FIG. 1 84. One week after injury. 

FIG. 185. ftesult. Note the overlapping at the 
angle produced by an " advancement " flap. 
This is amenable to secondary correction, but 
only the one operation was performed in this 

FIG. ISO. Excision and Incision. No mucous 
membrane was excised, as might bo inferred from 

FIG. 187. Suture. Note skin and mucous 
membrane suture at different sites. 


CASE 177 

This private was received after a gunshot wound which had destroyed half the skin 
of the upper lip and one-third of the veimilion border. He was admitted into the depait- 
msnt in the scarred and healed condition as shown in fig. 188, and had already received 
two or three plastic operations on the lip. The amount of loss of tissue is well shown in 
the diagram, representing the healthy tissue remaining after excision of the scar tissue 
in the upper lip. The scar tissue in the cheek was similarly excised. Under chlorofoim 
oxygen anaesthesia, in the sitting position, the scar tissue in the upper lip was excised com- 
pletely, except where it had involved the mucous membrane on the posterior suifacc. A 
large ascending flap from the cheek was taken to fill up this gap, as illustrated in dia- 
gram 189, and the mucous membrane surfaces readjusted. The healing was by first 
intention, but the result of the operation was to depress the corner of the mouth. 1 This 
was due to the base of the pedicle, flap " A" being too wide. Another secondary deformity 
occurred as a result of this operation on 3.4.17 in that, in drawing the two cut surfaces of 
the mucous membrane together, an unpleasant pouting of the corner of the mouth was 
produced. On 3.9.17 operation was again performed, the objects of which were to restore 
the left angle of the mouth to its proper level, to evert the mucous membrane and 
to attempt to thicken the border of the lip. In the first place, a reverse flap to that 
taken at the original operation was swung from the upper to the lower lip to correct the 
level of the corner of the mouth. This flap was not as big as is shown in diagram 
190, and it should be noted that it runs across the scar line of the first flap, and is in reality 
a partial replacement of the original flap. This manoeuvre was quite successful, as usual, 
in restoring the level of the corner of the mouth. In regard to the eversion of the mucous 
membrane of the upper lip, an arrow-head piece of skin was excised, as shown in the 
diagram ; the edges when sewn up produced a satisfactory eversion of the mucous mem- 
brane. To make this border more prominent, the subcutaneous fat and muscle from 
the upper part of the lip was dissected from above downwards, and, whilst still partially 
attached, was rolled down as a flap of tissue, which was then sutured into the free border, 
the method of which was by mattress sutures, as indicated in the diagram, fig. 191. The 
result of this procedure was quite definite in producing a prominence of the border of the 
lip, and the aesthetic result was satisfactory. Functionally, it was quite good, except 
that the mouth was not sufficiently large. But, as the patient was quite satisfied, he was 

1 See also Case 7, pagci 90, for method of avoiding this droop of the corner by excision of part of 
the natural lip. 



FIG. 1 89. Excision of scar and ascending flap. 

FIG. 188. Healed condition. 

Fio. 1 90. Correction for depression of angle of mouth. 

FIG. 191. Scheme to show arrow-head excision of skin, 
and method of rolling down the soft tissues of the lip 
to its edge, to produce prominence and presentation of 
the vermilion border. 

FIG. 192. Result. 



CASE 295 

Is that of an officer in the Field Artillei y. who was struck by a shell on September 27th, 
1916. He was admitted nine months later for plastic treatment in the condition shown 
in the first illustration. A large depressed scar ran horizontally across his check, ending 
in various small scars in the remains of the right half of the upper lip. The underlying 
loss of bone comprised the major portion of the right upper alveolar process and antciior 
wall of the right antrum. The mucous membrane loss was practically nil, whereas the 
skin of half the upper lip had been shot away, the vermilion border being drawn up by 
the scar tissue, producing a marked ectropion. The right corner of the mouth was 
normal, and the question of supplying the necessary amount of skin to cure this deformity 
presented many difficulties. Had I used an ordinary imbedded ascending flap, the corner 
of the mouth would undoubtedly have been seriously displaced, necessitating further 
correcting operations. Descending flaps were contra-indicated on account of the scar 
tissue and no hair being thereon. Two further designs presented themselves to me, both 
of the ascending flap variety, the first of which necessitated excising the already existing 
corner of the mouth, so as to imbed the flap, and it was therefore discarded ; the 
remaining method, which was the one adopted, was to use an ascending flap, but to 
imbed only the terminal portion of it, thus making it into a bridge flap, the pedicle 
lying over healthy, untouched skin. The vermilion border was carefully preserved and 
resutured, as is shown in the intermediate stage illustrations. The under raw surface 
of the bridge was protected by waxed gauze, while two silk-worm sutures were passed 
through the vermilion surface of both lips, at the right corner, in order to steady the 
parts and to prevent oral secretions reaching the wounds. The return of the pedicle 
was carried out on 7.9.17, i.e. on the eleventh day the bridge of the flap was cut in a 
slanting direction just clear of where it had been sutured into the upper lip, and the 
remaining free end of the graft was sutured into place. The pedicle of the bridge was 
re-fitted into the check, and in doing this a small amount of granulation tissue had to be 
cut away before the pedicle was replaced into its original position. It should be noted 
that the under surface of the bridge was kept exceedingly clean, No. 7 Ambrine wax dressing 
being used. The result, so far as the moustache and upper lip arc concerned, was all that 
one could desire, and at the second stage of the operation a small portion of the redundant 
mucous membrane was excised. As to the reinsertion of the pedicle, I doubt whether any 
advantage has accrued. Owing to the slight granulations on its under surface, there was 
a distinct tendency at first to present a somewhat rounded appearance ; but, although this 
has subsided, there was no necessity to preserve this piece of skin in this particular case, 
and the resulting scar-line might have been better than it is. 

In regard to the depression of the check and the long scar, a dental apparatus 
designed by Sir Francis Farmer has materially aided in bulging out the cheek ; but 
this did not fill up the hollow in the cheek. A considerable free fat graft was successfully 
implanted under the skin at a later stage, but the result of this is not illustrated. 

Fio. 193. Illustrating " bridge " pedicle flap for upper lip and moustache. 



FIG. 194. The healed condition nine months after 
wound. Ectropion from loss of skin surface. 

FIG. 1 95. Bridge pedicle flap in position. 

Flo. 190. Pedicle returned. Moustache grown, 

Fio. 1 97. Ditto. Note : the hollow in the cheek 
was filled by a free fat graft and excision of 
scar at a later stage. 



CASE 270 

This case of a minor injury of the upper lip is included for one or two reasons. It 
was due to the exit wound of a bullet which entered behind the right angle of the mandible, 
which it broke, passed through into the month, and carried a few of the front teeth through 
the upper lip. The blow in this case was very severe, and the officer told me that he felt 
as if the whole of the face had been shattered. There is no important loss of tissue, but 
the method of repair is interesting as an illustration of the value of overlapping flaps in 
producing depth. The wound had caused the stellate explosion of the upper lip, and when 
the case was sufficiently healed to conic for operation, six weeks after the battle of the 
Somme, it presented a somewhat similar appearance to that shown in the illustration 
which was taken in the semi-healed condition. The diagrams accompanying this record 
indicate how each radiation of the scar was excised, and the little flaps thus outlined were 
each prolonged by incision to a slight extent and then interlocked the one above the 
other. Comparing this case with that of 143 and others in section on lower lips, the 
value of this method of producing depth at the place one most wants it is, I think, estab- 
lished. The second illustration is that of the condition just after the removal of the 
stitches and the scar lines are plainly visible. When this officer returned to duty, he sent 
me a photograph taken by an ordinary lay-photographer ; the growth of the moustache 
has effected a perfect result. 

Fio. 1 98. Exit wound of bullet. Semi-healed 



Fict. 1 99. Exoision and Incision 

FIG. 200. Suture. 

Fia. 201. On removal of stitches. 

FIG. 202. Result. Photo taken by lay 


CASE 179 

This is a very atypical deformity of the upper lip caused by a gunshot wound, received 
on August 18th, 1916, details of which are lacking owing to the fact that the patient was 
not admitted to me until March 1st, 1917, in the healed condition shown. 

The scar near the angle of the mouth produced a very marked deformity of the upper 
lip, and this case is not so much one of a restoration as it is one of a deformity. The interest 
of the case, I think, revolves round the principle with which such condition should be treated. 
The method actually used is very clearly shown in the diagrams. The large descending 
flap, A, from the cheek, was swung down beyond the corner of the mouth, after excision 
of all scar tissue. The natural flap, produced by excision of the scar, was stretched 
upwards and backwards. The marked eversion of the vermilion border was very satis- 
factorily cured, and the gain of tissue necessary to maintain this result was obtained at. 
the expense of the tissue beneath the left eye, and the tension of this flap, which would 
have a natural tendency to recede upwards, was taken from the flap, B, which, being 
attached to the lower lip, prevented any late alteration in the replaced upper lip. 

The photograph of the result was taken seven weeks after operation. 



FIG. 203. Nine months after wound. 

Fio. 204. Excision and flaps. Flap B referred to 
in text is that just below A. 

Fio. 205. Suture. Flap .1 ' brought down to 
a lower lip attachment at A. B (not marked) 
swung backwards. 

FIQ. 200. Result seven weeks after operation. 




THIS chapter includes injuries to the lower lip, certain injuries involving both 
lips and leading to conditions of contracted mouth, and injxvries to the soft 
and hard tissues of the chin. 

The injuries to the lower lip are arranged roughly in order of increasing 
severity. There is a certain definite group which may be termed the Hare 
Lip type, in which a satisfactory repair may be obtained by a simple advance- 
ment of the remaining portions, the aesthetic and functional results varying 
directly with the amount of tissue lost. When more than one-third of the 
lower lip is missing, the result of the advancement repair ceases as a rule to 
be satisfactory. It sometimes happens that the resulting diminished lower 
lip fits in well with the loss of bony chin. 

But in planning all repairs of the lower lip, .the first thought of the surgeon 
must be to provide a satisfactory bed for a denture, with a buccal orifice of 
such a size as will admit the necessary temporary or permanent appliance. 

In the group of injuries leading to microstoma no account is taken of facial 
burns, which, in the author's opinion, are by far the commonest cause of the 
condition. Another important cause that should be here mentioned is inex- 
perienced surgical procedure, such as omission to provide a lining membrane 
for flaps. 

Injuries to the chin naturally divide themselves into those of the soft tissues 
only in which good functional and aesthetic repair is the rule and those 
involving loss of bone. In those terrible cases in which the whole of the mandible 
from molar region to molar region is carried away, the author has neither seen 
nor performed any series of operations which may be said to have achieved 
more than mediocre result as regards appearance and more than a very pool- 
result as regards function. The condition is one analogous to loss of a limb, 
and in the upshot a presentable appearance is often the mask of a skeleton of 
surgical inefficacy. 

The most serious difficulty in the way of functional repair is the provision 
of a depressor musculature for the new jaw. One has several times seen what 



appeared to be a moderately satisfactory repair, including a successful bone- 
graft, prove wcllnigh worthless from lack of attachment of the suprahyoid 
muscles and platysma. Little or no excursion of the mandible occurs, and 
there remains a gross impairment of speech and of the first stage of deglutition. 
It should be noted that the remaining fragment of the mandible assumes a 
position determined by the removal of the muscles opposing the internal ptery- 
goid, temporal, and external ptcrygoid muscles, as well as of the support afforded 
by its continuity with the condyle of the opposite side. It is therefore swung 
upwards, forwards and inwards, and somewhat protruded, and when the patient 
tries to open his mouth, the deformity is merely accentuated. 

In the attempt to provide a depressor musculature, in one case, in which 
all idea of the formation of a bony chin had been abandoned in favour of an 
intrabuccal dental appliance, the author dissected out and epithelialised what 
remained of the anterior belly of the digastric. 

The idea was to introduce it into the floor of the mouth, with a view to 
attaching it to the denture by means of an artificial tendon after the manner 
of Putti. But the exigencies of the service, and in the urgent necessity of 
making the major repairs in this case, prevented the fulfilment of the plan. 

There is, moreover, in these cases a total lack of control of the lower lip. 
The author, in the attempt to relieve this, uses descending nasolabial flaps 
which include some muscular fibres with nerve supply intact. These continue 
to function in their new position, and, by tightening, effect some degree of 
closure of the buccal orifice. 

The simplest and, fortunately, the most common injury of the lower lip 
is of the hare-lip variety, which requires for its repair excision of the scar, com- 
bined with accurate resuture, and advancement or elevation of the tissues. 

Where the lesion occurs near the corners of the lower lip it is the common 
practice to advance the tissue situated laterally to the scar. The point of the 
chin in these cases is usually in its normal position, and so the gain of tissue 
that is required is obtained from the lateral aspect after excision of the scar. 

A few cases illustrating this deformity are appended. 



Case 50 shows a lesion of the lower lip in the same region as in the previous cases, 
with ectropion from scar tissue contraction. The diagram illustrates the method by 
means of which the ascending flap was swung up to fill in the gap and to raise the lip. 
No special point is to be noted in this case except that flap A was inserted between the lip 
and the chin, and flap A being wedge-shaped, the more it was drawn in between them the 
more the lip was raised. 

FIG. 207. Healed condition. (Note ectropion of lip.) 

FIG. 208. Excision of scar and freeing of flap. 

FIG. 209. Suture. 

FIG. 210. Result. 


CASE 244 

This case was wounded in Mesopotamia by a bullet which entered into the left super- 
ciliary margin, and after perforating the bone there, re-entered it just below the left eye, 
perforating also the left antrum and palate, and then carried through the lower jaw and 
left side of the lower lip. 

The external wounds were healed on admission to the Cambridge Hospital, Aldershot, 
and the mandible, after sequestrotomy and extraction of involved teeth, united. The 
palate was also replaced by a dental appliance, under the supervision of Captain L. A. B. 
King, R.A.M.C. 

The lower lip was treated in the following manner : The loss of tissue being trifling, 
the scar was freely excised and adhesion to the mandible freed. Three natural flaps were 
thus outlined, and the two lateral ones advanced in the V Y fashion. The mucous membrane 
was treated separately and specially, so as not to get depression at the point of union. The 
vermilion border attached to the left corner of the mouth was dissected back to the corner 
along the muco-cutaneous junction ; that on the main portion of the lip was similarly divided 
along the muco-cutaneous border until it could be easily advanced to the left corner of the 
lip, where it was resutured. Its upper border was then freshened, and the little flap attached 
to the left corner sutured into this freshened area. The advantage of this method of dealing 
with the mucous-membrane suture is that the union of the two halves of the vermilion 
border is on a different vertical plane from that of the skin, and there is no tendency to 
a dimple at the junction. 

Two of the photographs illustrating this case are of pastel drawings by Professor Henry 
Tonks, the ordinary negatives not being available. 





Fio. 211. Healed condition. 

Fio. 212. After operation. 

Mucous flap 
turned back 
Raw surface shaded 
to meet similar 
raised surface on A- 

FIG. 213. 


CASE 58 

was a Royal Flying Corps officer, who was wounded by seven machine-gun bullets, at Kut, 
in Mesopotamia. The wound that is here illustrated was caused by one of the bullets. 

There was a loss of mandible of about one and a half inches in the right prc-molar region. 
The dense scar in this region extended up to the vermilion border of the lip, which was 
dragged down with it. The scar was of a radiating character, and, on excision, it was found 
that the free portion of the lip came back into position easily, but in order to fill up the 
large gap, caused by the excision of the scar, with healthy tissue, it was necessary to make 
a swinging advancement of the cheek in the neighbourhood. This is illustrated in the 
diagram, and is visible in the photograph showing the result. This flap also prevented a 
tendency to eversion of the lip on the one hand, and, on the other, to the displacement of 
the soft tissues of the chin to the right, which would have occurred had a straight " sew-up " 
been attempted. 

This officer was submitted to a bone-graft operation seven months after being wounded, 
and four months after the plastic. The bone-graft was eminently successful, and notes of 
this operation and of X-rays follow : 

17.3.17. Operation (Captain Gillies). Ends of bone cut down upon and isolated from 
adherent tissues, and inferior dental canal in both fragments reamed out. A gap of one inch 
separated the fragments. A rib-graft was taken from right thorax with periosteum attached 
on outer surface, with an overlap of about half an inch at each end. The extremities of 
graft were pointed and these points engaged in reamed-out canal of fractured ends of man- 
dible. Wound sutured with horsehair. Drainage (gut). Wound healed by primary 

23.4.17. X-ray shows bone-graft in excellent position. Much callus being thrown 
out around its posterior anchorage. 

February 1919. Examined by the judging committee of the Odontological Section 
of the Royal Society of Medicine, and pronounced to have firm bony union and 90 per cent, 

This and the preceding cases had no serious shortage of the mucous membrane. 



FIG. 214. Healed condition. 

Fm. 215. Excision of scar and advancement 
of cheek flap. 


Fio. 216 Suture. 

FIG. 217. Result. 


The next cases are examples of injuries to the corners of the mouth, and 
do not exactly belong to either the Upper or Lower Lip group. 


In Case 5 a large piece of shell entered at one angle of the mouth and eame out through 
the opposite side, fracturing the mandible and tearing away the adjacent portions of the 
cheek. This patient was wounded on July 1st, 1916, and fig. 218 shows the rendition on 
admission two days after being hit. Unfortunately, a graphic record of his healed condition 
was not taken. The X-rays showed fracture of the mandible in two places in the region 
of the first molar tooth, and in the region of the symphysis, the intermediate portion of 
bone being displaced. 

Plastic operation was undertaken on September llth, 1916, and consisted in excision 
of scars on both sides. 

On the right side the two surfaces of the cheek were merely drawn together, and the 
mucous membrane from the inside of the mouth brought out to form a new angle (fig. 219). 

On the left side, a combined skin and mucous membrane flap was swung towards the 
oral opening both in the upper and lower lips (vide figs. 219 and 220). 

FIG. 218. Early condition. 

Fio. 219. First plastic. Excision and suture. 

The result of this operation was satisfactory, except that the movement of the lower 
jaw began to stretch the line of union of the flaps on the right side of the cheek, and the 
wound partially broke down near the corners of the mouth (fig. 221). It was limited by 
immediately fitting a closely applied chin-splint and attaching it over the head. Since 
then, in all eases in this region, I have been careful to support the lower jaw until the opera- 
tion wound is well healed. 

Second plastic operation (October 31st, 1916). Scar re-excised, and, in order to raise 
the corner of the mouth a little, a flap was outlined as per diagram (fig. 223) and sutured to 
the lower lip. 

Third plastic operation (January 1st, 1917). A portion of the right scar having again 
broken down, it was re-excised, the knife being used obliquely to the skin surface. Local 
iat-flaps were turned in from above and below the depression, sutured together with catgut, 



and the skin sewn over this pad with fine interrupted horsehair. A small mucous membrane 
correction was made on the left upper lip, and the left lower lip was raised at the corner by 
sewing up perpendicularly a horizontal incision through the whole thickness of the lip 
(fig, 224). 

FIG. 221. After first plastic. 

FIG. 222. Final. 

FIG. 223. Second plastic. 

FIG. 224. Method used to raise lower lip. 

Figs. 218, 222 and 221 show the condition before and ; after treatment, and the stage 
after the first operation. 

Firm bony union of the lower jaw has occurred, and the patient can eat solid food. 
Further improvement could be effected by bringing down the upper lip at the left angle. 

The dental work was carried out by Captain F. E. Sprawson, R.A.M.C. 

The diagrams illustrating the operations were drawn by Professor Henry Tonks. 


CASE 563 

Probably at the time of injury this was a similar type to that of Case 5, but a less 
serious wound. 

The mouth had healed well, but with a marked microstoma, which was a functional 
disability. There were also disfiguring scars at the corners of the mouth. 

Previous history was not obtainable, and the only interest in the case is that of the 
widening of the buccal orifice. A thin, triangular portion of skin and scar tissue was 
excised at each angle of the mouth. The mucous membrane was well divided in the middle, 
and then sutured to the skin. 

The improvement in the microstoma was very marked, and the appearance was quite 
satisfactory, although the photograph of the final condition was taken without the presence 
of dentures. 

I include this case because I think a slightly better appearance is obtained when a 
small portion of the skin and subcutaneous tissue is excised to allow the mucous membrane 
to curl round and show itself. 




FIG. 225. Healed condition. 

Fio. 226. Microstoma relieved. 


Three cases of loss of the central portion of the lower lip are next discussed. 

In two of these the condition seen after wounding is represented photo- 
graphically, and in one of them (Case 62) the healed stage is available. 

I'nfamiliarity with this class of injury leads one to think that the material 
loss is very much greater than it actually is. 

CASE 62 

Corporal C , was admitted on 6.7.16, five days after being wounded, with fracture of 

the jaw in the symphysis region and loss of the middle third of the lip. 

When the bone condition had been successfully controlled and the sequestra had all 
come away, a plastic operation was performed for me by Lieutenant Dixon, R.A.M.C., 
with the assistance of Lieutenant C. B. Tudehope, R.A.M.C., and after excision of the scar, 
which went down to the bone, the flap on the right was swung upwards and to the left, 
while that on the left was undercut and raised. 

The new lower lip was considerably shorter than his original one, but is sufficiently 
satisfactory from both cosmetic and functional points of view. 

Flo. 227. On admission. 

FiG.228. Healed condition. 



FIG. 229. Excision of Scar : flaps outlined. 

Fio. 230. After first plastic. 

FIG. 231. Final after excision of scar. 



CASE 256 

Another type treated by excision of scar, 
and raising of the halves of the lip, is also 

Note the apparent seventy of the lip 
injury, which is obviously a photographic 

The operation notes are : 

Private Mc.H , admitted 19.8.16. 

Condition. Slight loss of tissue of lower 
lip with the two halves firmly united to man- 
dible and presenting a V-shaped gap. 

29.9.16. Operation (Lieutenant Tude- 
hopc). Type freeing of lip-halves and pro- 
longation of the incision lateralwards to allow 
necessary depth on resuture. 

Result. Satisfactory. Slight scarring. 
Discharged, duty, 7.2.17. 

FIG. 222. Early condition. 

Fio. 233. Healed condition. 

Fid. 234. After lip plastic. 



CASE 205 

This is another simple type giving satisfactory result. 

It was necessary, however, very carefully to adjust the mucous membrane on the inner 
side of the flap. 

The jaw was in process of uniting, and an artificial set of teeth was fitted over the 
splint (Captain L. A. B. King, R.A.M.C.), to enable the plastic to be more accurately per- 

FIG. 235. Healed condition. 

FIG. 236. After plastic. 



The following two cases show clearly the loss of the lip and its red margin, 
reparable by a forward-swung mucous membrane flap. In each case the skin and 
subcutaneous tissue loss was made good by a descending flap, or flap of election, 
taken from the nasolabial fold. 

CASE 198 

showed a elean loss of the central third of the free portion of the lower lip. The scar having 
been excised, the mucous membrane was advanced across the gap, and a flap of suitable 
size, was brought down from the left of the nasolabial fold, and sutured into position. The 
terminal portion of this flap, for an obscure reason, went blue, and was lost through dry 
gangrene. Perhaps the pedicle of this flap was a little too small. 

The result after the operation wound had healed as shown in the second photograph, 
and presents an ugly scar and notch in the middle line. Later, this was excised, and by a 
VY double swinging advancement a deep and satisfactory lip was obtained. 

FlO. 237. On admission. 



'&:. Mucous flap from 
inside of cheek. 

FIG. 238. Steps in first plastic. 

Fia. 239. After Orst plastic. 

FIG. 240. Final plastic. 




Tlie mucous membrane shown in Professor Tonks's pastel (photo represented) was 
carefully preserved by stitching it to the skin margin in the early stages of this man's wound. 

\Ylten the large wound on the right side of the check had healed, a plastic operation 
was undertaken for me by Lieutenant C. B. Tudehope, R.A.M.C. The corner of the mouth 
had been dragged down by the sear, and was relieved by its excision. In order to improve 
the position of the corner of the mouth and maintain it at a correct level, a descending 
flap from the right nasolabial fold, containing skin and subcutaneous tissue, was swung 
down and sutured beneath the readjusted vermilion border. A pleasing effect was thereby 
produced, but it might have been possible to raise the centre of the lip a shade more by 
making the flap a little longer. 

Fio. 241. Early condition. 

FIG. 242. After plastic. 



CASE 243 

This needs little explanation. Not only were the two lateral flaps, A and A', advanced 
and swung upwards in the V Y fashion, but the apex of the V was itself raised by suture to 
the deep tissues. The result is suffieiently satisfactory. The bone lesion was one of con- 
siderable comminution, and the case healed with a pseudarthrosis in the mandible. This 
was treated by excision, and inlay of an osteo-periosteal graft from the tibia, with the 
result that bony union occurred. Five months after the bone operation the patient was 
discharged to duty. 

FIG. 243. Healed condition. 

FIG. 244. Excision of scar and delimitation of flaps. 


Via. 245. Suture. 

Fia. 240. Result. 

1 I'-' 


CASE 45 

Graphic records of the condition on the tenth day after wound and after the parts 
became soundly healed are given. 

The loss of tissue comprised the left half of the lip in all its layers, the shortage of 
mucous membrane being considerable. 

The method of plastic repair consisted of a descending nasolabial flap for the skin and 
muscular layers, combined with an advancement flap of the mucous membrane. 

The result was fairly satisfactory from the cosmetic point of view, but there is no doubt 
that the mucous membrane was still very short, and, owing to adhesion between the new 
lower lip and cheek and the mandible on the left side, the fitting of an artificial denture 
became a serious difficulty. This was subsequently remedied by an epithelial inlay by 
KSMT'S method, with moderately good functional result. 

I think the mucous membrane difficulty in this case might have been better met in 
the first instance by taking a whole-thickness flap from the nasolabial region. An alternative 
which would have acted well would have been to make a new sulcus along the mandible 
before undertaking the plastic closure. Another way of dealing with this, but requiring 
more extensive flaps, would have been to turn in the skin in the neighbourhood of the 
scar to form the buccal lining. 

It will be noted that the nasolabial flap was carried to a point, the reason for which 
has already been discussed. 

Fio. 247. Early condition. 





FIG. 248. Healed condition. 

Fio. 249. Excision of scar and delineation of 
descending nasolabial flap. 

FIG. 250. Suture. 

FIG. 251. Present stage. 



'1 his case is one of interest and also of partial failure. The interest lies in the ring-like 
injury of the month. 

The mucous membrane healed with great tendency to keloidal scar tissue, and. despite 
the persistent use of apparatus, made under the supervision of Captain L. A. B. King, 
R.A.M.C., attempts to prevent the mouth contracting failed, and a marked condition of 
mierostorna was present when the lips were healed. The buccal orifice was surrounded by 
an unyielding ring of scar tissue, giving a maximum width of 1J inches. The loss of tissue 
\\;IN mainly in the lower lip, the mucous membrane of which was entirely absent. 
Before plastic repair, a preliminary excision of all scar tissue was performed. 
In regard to the upper lip, careful resuture, combined with the pulling out of the 
mucous membrane, gave a sufficiently satisfactory result. 

For the lower lip, double nasolabial descending flaps were used, that on the left being 
longer than that on the right. These were taken down to the muscular layer only, part 
of which was included in the flap. Such mucous membrane as was provided for this lip 
was taken from a similar area to the skin-flaps, but as independent flaps. The result was 
moderate so far as appearance is concerned, and the fault was due to the fact that there 
was a great shortage of the lining membrane of the lip and of the lower sulcus, which pre- 
vented the fitting of. a satisfactory lower denture. 

This patient refused further treatment at the time, but there is no doubt that a most 
satisfactory functional and cosmetic effect would be produced by a successful epithelial 
inlay between the gum and new lower lip. The scar tissue of the lower lip had been very 
successfully got rid of, and the new one was of great softness and pliability, with a certain 
amount of muscular movement, which made one regret the inability to complete the case. 

Flo. 252. Early condition. 



Fia. 253. Healed condition. 

FIG. 25-t. Excision of scar and outlining of flaps. 

Fio. 255. Suture. 

FIG. 250. Final. 
(I'atient refused further treatment.) 





The diagnosis in these injuries rests on the accurate estimation of the tissues 

CASE 99 

The photograph taken on admission seven days after the receiving of the wound shows 
that the loss of tissue comprised the right two-thirds of the free border of the lower lip, 
together with an injury of the cheek. The destruction of the mucous membrane does not 
go down to the lower buccal sulcus ; consequently, the shortage of mucous membrane is 
not so great as it might appear from examination of the photographic record. The photo 
of the healed condition is not available. 

The result of the first operation was moderately good. The operation notes show that 
when the scar tissue was removed the loss of tissue was roughly represented by what I have 
already described and what was apparent before the healing had commenced. 

Two swinging advancement flaps were utilised to make good the main body of the lip, 
while mucous flaps were able to be cut and brought out to remake the vermilion border. 
Subsequent minor corrections were carried out to overcome this shortage, the main one 
of which consisted of a flap of mucous membrane, taken from the upper lip and sewn to 
the lower. 

Note. On discharge from hospital the mouth was slightly contracted. 

Fio. 257. Early condition. 

Fio. 258. Excision of scar and outlining of flaps. 




Via. 259. Suture. 

Fio. 260. Early result. 

FIG. 261. After minor corrections. 



CASE 137 

Private W - is the only example in this series of cases in which a combined skin, 
muscle, and mucous membrane flap was taken from the nasolabial fold and brought down 
to make the lip. The loss of tissue in the early and healed conditions is shown in ligs. 
2(52 and 263. The shortage of mucous membrane was rather greater than is apparent. 

This whole-thickness flap, cut with square ends, was found to be too thick when brought 
down, and the middle fatty layer was dissected out from the outer and inner edges in order 
to reduce its thickness. (See Professor Tonks's diagrams.) Even then, the lip was a little 
too fat, and bad suture lines spoiled what would otherwise have been a very perfect result. 
The lip had excellent function, and was very pliable. 

Diagrams are below, and the record of the condition of this man on admission is a re- 
production of one of Professor Tonks's exceptional drawings in pastel. 

FIG. 2fi2. Early condition. 



Fia. 263. Healed condition. 

Fio. 204. Excision of scar and outlining of (lap. 

FIG. 265. Excision of fatty layer from flap. 

FIG. 260. Suture. 

Fio. 207. Final. 


CASE 184 

This case is one full of interest in all its stages. This gallant trooper was wounded and 
eaptured while on distant outpost duty in the wilds of East Africa. In addition to a 
fractured arm and loss of the lower lip, severe dysentery followed owing to insufficient 
medical care. He made good his escape, and, after tramping through the Bush country 
a journey of about 150 miles he managed to get under British medical treatment. 

lie had been operated on twice by his captors for his jaw condition, and on eventually 
arriving in my clinic all wounds were healed and his condition was as shown in fig. 268. The 
loss comprised the greater part of the free portion of the lower lip in all its layers. A 
stump of the lip remained, however, at each corner. 

The first operation was moderately success- 
ful, and its method of gaining tissue to remake 
the lower lip consisted of a partially descending 
swinging advancement from the left cheek, and 
this flap was drawn and sutured above the 
existing chin skin, and the mucous membrane 
from either side advanced over its upper border. 
The diagram roughly represents its principle. 

Five months later, the new lip was in a con- 
dition of entropion, as would be expected, the 
mucous membrane being too short to allow the lip 
to be sufficiently free. In addition, there was no 
inferior sulcus on which an efficient denture could 
be carried, a condition which was accentuated by 
the fact that the alveolar bone had been de- 
stroyed. It was decided to employ the Esser 
inlay for this entropic condition, with most 
satisfactory results, the date of this operation 
being 21.9.17. 

This was the first of its kind that the author 
had done, or seen done, and it was probably the 
first case treated by this method in this country. 
FIG. 208. Healed condition. A discussion on the matter with Major Waldron 

Fid. 269. Descending nasolabial flap. 

FIG. 270. Suture. 



FIG. 271. Condition after descending nasolabial 
flap operation. 

C.A.M.C., who advised the perusal of Esser's 
article, led to the adoption of this means of 
treating the condition. 

An exceptionally efficient denture was 
now applicable, and in the fitting of this the 
patient had the advantage of Sir Francis 
Farmer's skill. 

Following the freeing of this lip by the 
Esser inlay, the lip was raised by a nasola- 
bial fold, taken from the left side. A marked 
bossing of this flap occurred, which diminished 
very slowly, and the reason for this lymphatic 
stasis is, as yet, I think, an undiscovered 

One has not discovered the reason why 
some of these flaps show this rounding and 
others not. In this particular case, it is pos- 
sible that the skin-graft on the inner aspect 
of the lip had something to do with the ab- 
sence of drainage from the area. 
In addition to this being due to lymphatic blockage, there is undoubtedly a certain 
amount of fibrosis which occurs in the bed of the flap. For this reason, it was decided to 
operate again, and at the same time to get. an everted free margin of the lower lip. Incision 
was made along the line A B in fig. 272, which lay along the existing muco-cutaneous 
junction. This incision also was carried down along the suture-line to the right, the scar 
of the suture-line being excised. The skin was then carefully undermined, leaving the 
subcutaneous tissue in position, and this undermining was continued below the lower scar 
of the rounded flap. Then a large amount of the subcutaneous tissue was dissected from 
below upwards, and made to lie between the mucous membrane and skin of the original 
incision, as shown in the diagram, D in fig. 273. This allowed the skin of the rounded flap to 
go flat. Next, the now exposed fat-flap D lying between the skin and the mucous membrane 
was covered by mucous membrane flap C from the 
upper lip. 

The method of making a vermilion border from one 
lip to the other is typified in this case. I give particulars 
of the technique used. The upper lip was well raised 
forward, and the mouth well packed to prevent blood 
going down, and incision was made along the gingivolabial 
junction of the central portion of the upper lip. Two 
perpendicular cuts to the free margin were carried from 
extremities of this incision. This mucous flap, thus out- 
lined, was reflected from above downwards until it well 
covered the fat flap D without tension. The sutures 
necessary to retain this mucous membrane flap were 
now inserted without being tied ; they consisted of one 
relaxation suture of silk-worm gut from the upper lip to 

the chin, next a row of four horsehair sutures was 

' _ , FIG. 272. Incision along muco 

inserted through the mucous nap, and lour mat.ress cutaneous junction (D the 'dotted 

area, represents a subcutaneous flap 
which was elevated to form a basis 
for new vermilion border.) 

horsehair sutures through the mucous flap joining it to 
the mucous membrane of the lower lip. These were in- 
serted about \ in. from the free border of the mucous 
flap, so that sufficient mucous membrane remained to go over D to join the skin. 
These sutures being got into position, the mouth plugging was removed, and relaxation 
and backrow sutures were tied. It remained to join the free edge of the mucous flap to the 
skin of the lower lip. An anaesthetic was given for this operation by Captain J. C. 

1 .->_> 


Clayton, R.A.M.C., ether, nasal tubes, and mouth-packing being used a particularly 
satisfactory procedure in this case. 

Diagrams of this procedure and a photograph of the lip in this stage showing the back 
row of sutures in position accompany these notes. 

FIG. 273. Subcutaneous fat flap (D) 
being raised from chin region to help form 

FIG. 274. Mucous flap from upper 
lip outlined. 

Fia. 27C. Front view of Fig. 275. 

Fia. 275. Mucous flap swung from 
upper to lower lip. 

Fia. 277. Mucous flap being sutured into place. 
(Note retention suture.) 



The broad pedicle of this mucous flap was detached under novocaine ten days later. 
Feeding was maintained by passing a tube through the corner of the mouth. 

Owing to the excellent result, one was encouraged to fill up the corners by mucous- 
membrane flaps from the lateral portions of the upper lip, 

Anaesthesia for this operation was obtained by blocking the infra-orbital nerve at its 
exit from the canal, and by local novocaine infiltration to the lower lip. 

FIG. 278. Mucous flap from upper lip applied to 
lower lip. (Patient fed through a tube in corner 
of mouth.) 

FIG. 279. Final, showing new vermilion border 
for lower lip. 


CASE 188 

A very good result was obtained in this case. The healed and early conditions 
show a loss of more than half of the lower lip through all its thickness, but the tissues 
of the chin are merely displaced in the freshly wounded condition. 

Only one operation was done on this lip, and by good fortune a more than satisfactory 
result was obtained by it. The main principle of it was a descending nasolabial fold- flap, 
which was deepened to the muscular layer only and brought down to meet the right portion 
of the lip remaining, which was, at the same time, advanced and raised. The lining was 
obtained by freeing a stump of mucous membrane present at the left corner of the mouth, 
and converting it by undercutting into a flap which was advanced across the new lip to 
meet the existing vermilion border of the right. 

A large gap in the bone, some 2| in., now existed, and a bone-graft operation was 
performed ten months after the wound. The rib-graft was wedged between the fragments, 
and a bone-peg was used to fix the posterior end of the graft to the angle of the ascending 
ramus. The patient was edentulous, and the difficulty of the fixation of the fragments 
was not sufficiently overcome to obtain fixation of the graft. It was noticed on the fourth 
day that a drop or two of fluid came away from the mouth, which was due to the bone-peg 
working loose and perforating the mucous membrane. Inevitable suppuration followed, 
and the graft was eventually removed. Its place was, however, taken by a strong ostco- 
fibrous band, which was of some functional use to the patient, whose age was thirty-five. 



FIG. 280. Early condition. 

FIG. 281. Henled condition. 

FiQ. 282. After plastic and bone graft. 


CASE 236 

This was a combined case of Captain Aymard's and the author's. This South African 
soldier was severely wounded in the lower lip and mandible, in the battle of the Somnie. The 
healed condition is not shown. The loss of tissue consisted of the central two-thirds of the 
free margin. The natural flap, which is shown lying semi-detached in the first photograph, 
was utilised by me in the first operation. This natural flap was enlarged by incisions in the 
downward direction, and maintained by deep catgut sutures to the periosteum of the surface 
of the symphysis. A mucous flap was drawn from the left side to cover a portion of the lip. 

Captain Aymard, K.A.M.C., then undertook the completion of the case, and by ad- 
vancement of flaps, shown in the diagram, achieved a deepening and widening of the lower 
lip, while the mucous membrane was provided from the upper lip. 

The appearance of tin's new vermilion border was distinctly pleasing. 


FlO. 283. Early condition. 




Fio. 284. After first "plastic. 

Fia. 285. Mucous flap from upper for lower lip 
and skin flaps outlined. 

I I 

Fio. 2SG. Flaps swung and sutured. 

Fio. 287. Final. 


CASE 535 

This soldier received a shell-wound of the mandible and chin. The destruction involved 
the mandible to the extent of some two and a half inches between the left canine and the 
right molar region ; it involved the soft tissues over a similar area, but the mucous membrane 
of the left third of the lower lip remained, and the healing process extended downwards 
along the raw edge. 

The fragments of the mandible were maintained in a good position in the early stages 
by dental splints. 

The case cleaned up rapidly, as such cases of large losses usually do. 

The method of repair designed was by double epithelial flaps, and as a preliminary 
the defined area outlined for the flap, which was going to be turned skin surface inwards, 
was subjected to X-rays for epilation. The effect of this was not entirely satisfactory as 
regards the killing of the hair follicles, even though it was pushed to the extent of causing 
a small burn. 

The first operation was performed on the line designed, and the skin below and lateral 
to the gap was raised in two flaps and turned skin surface inwards, and there sutured to the 
existing mucous membrane. Along the top of this new skin-lining the remaining mucous 
membrane was stretched and found to be adequate to complete the vermilion border. The 
raw area caused by this transposition of skin was accurately measured with a template and 
a flap of skin from the right aspect of the neck and chest swung upwards to fill the gap. 
The area from which this flap was taken was partly closed by approximation and partly 
left open to heal by granulation. 

The result was satisfactory. 

This operation was performed over a prosthesis representing the missing portion of 
the mandible, supported laterally on the two fragments. It was found, however, that in 
the after-treatment the pressure of the flaps on the apparatus was too great, and the latter 
was removed to avoid gangrene. It was found later that the new chin and lip were so soft 
that they could easily be pushed out into any position. The result of this stage is shown 
in fig. 292. 

In addition to the lack of depth of the new lip, there was marked absence of movement 
in this newly made portion. To improve both of these defects, it was decided to swing 
down a nasolabial flap on the right side and to interpose it between the upper border of the 
neck-flap and the vermilion border. The vermilion border and the inturned skin-flaps were 
freely undercut, so that they could be lengthened to cover over satisfactorily the inner 
surface of the nasolabial flap. 

The result was gratifying, both as regards appearance and movement of the lip, the 
latter being quite remarkable. 

It remains to insert a bone-graft of the necessary length, which should present no 

The method adopted in this case is better than that in the one which follows. 

The fragments of the mandible were maintained in better position, in the first place 
by splints, and in the second by the turning-in of an adequate epithelial lining, while in 
the next case the mandibular arch was contracted mainly due to advancing the existing 
mucous membrane across the gap. 



Fio. 288. Early condition. 

Fio. 289. Healed condition (full face). 

I , YlJX r ^x 

i *&~~^ / v ^ 

FIG. 290. Healed condition (profile). 

FIG. 291. Showing inturned flaps for lining and 
ascending neck flap for covering of new lower lip. 



FlO. 292.-- After first plastic : no muscular 
control of lip. 

FIG. 293. Nasolabial cutaneo-muscular flap 
brought down. 

FIG. 291. Present condition. 



CASE 160 

This case did not require any special flap to complete repair after excision of the scar. 
There was a considerable soft-tissue gap to fill, and the point of the chin was pulled to the 
right by the suture. 

The early condition of this patient was not recorded by photograph, but in the wound 
on the right side the body of the mandible was exposed for fully one inch and a half, as a 
wide devitalised piece of bone. It was, however, firmly attached to the posterior fragment, 
and, as a means of maintaining the position of this fragment, I retained it and passed a silver 
wire from the extremity of this dead end to the anterior fragment. 

In the course of time this fragment was exfoliated and the wire taken out. 

At the plastic, performed on 19.3.17, a gap in the bone still persisted, which was treated 
by an osteo-periosteal inlay, by the following method : 

The loss of bone was more of the lower than of the alveolar border, and after freshening 
the ends it was found possible to put a retaining wire through the alveolar portions. In 
elevating the mucous membrane from the bone, however, a perforation in the buccal cavity 
occurred, which was closed as far as possible by catgut sutures. Across the main portion 
of the gap an osteo-periosteal graft was laid in two portions : one on the internal and another 
on the external aspect. 

Some mild suppuration occurred after this operation, with a few drops of pus per day, 
which persisted until a few small splinters of the grafted bone came away and the wire 
was removed. Bony union was obtained by allowing the posterior fragment to swing 
forward a little, and the graft probably only acted as a means of carrying bone-forming 
cells from one fragment to the other. There was still a depression of the scar after bony 
union had been obtained, and the cicatrix was removed and a free fat graft, from the ab- 
dominal wall, inserted, to reproduce the contour. This was done on 7.9.17, and the 
effect is well seen in the photograph, which was taken two months after the operation. 

The scar in the neck is one made for ligature of the external carotid artery. 

FIG. 295. Healed condition. 

FIG. 296. Intermediate stage. 

FIG. 297. Final. 



CASE 79 

This is a type of case which is intermediate between the preceding group and the two 
cases that are next described, and is characterised by a very large loss of chin and lower 
lip, together with the underlying bone. But the way in which this case differs from the 
more extensive loss is that a considerable amount of the vermilion border has been preserved 
as well as the lateral portion of the chin. 

Fig. 299 shows the case after it healed, and with an appliance over which the plastic 
operation was performed. The principle of this operation was that the existing vermilion 
border was utilised to form the new lip margin ; and mucous flaps were drawn from inside 
the mouth across the back of the new lip. 

To make good the loss of the chin, a large descending flap, from the left nasolabial area, 
was swung down and sutured to the surrounding parts, over the prosthesis. The end of 
this flap was lost through want of blood-supply, and the reason of its loss was twofold. 
In the first place, there was rather a sharp edge to the appliance, and in suturing this long 
flap a double retention suture, with buttons, from the flap to the sound tissues on the right 
was utilised. This suture pressed the flap too firmly to the edge of the prosthesis, and by 
the time the blueness of the flap was observed, it was too late to save it. The other reason 
probably was that it had no skin lining on its oral surface. The result after this accident 
had occurred and the parts had all healed up, is shown in the next diagram, and a second 
plastic operation was done two and a half months later. 

The flaps are indicated in the diagram, and the final plastic result is shown, photographs 
taken a year later. 

During this interval a long rib-graft had been attempted from one fragment to the 
other. The operation wound of the bone-graft healed by first intention, and no discharge 
occurred subsequently. However, owing to probably insufficient apposition between the 
bone-graft and the mandible, bony union did not occur, and some absorption of the graft 
took place. 

A moderately satisfactory dental appliance, in the form of a denture, was however 
fitted, and semi-solid diet could be managed with the aid of this appliance. 

Notes of case are given below : 

Private C. L , wounded, France, June 30th, 1916, admitted 2.7.16. G.S.W. 2, 

1 severe, 4 lower jaw. 

2.12.16. Operation (Captain Gillies). For the formation of the lower lip and chin. 
Owing to lateral scarring, the only flap from the face available was one taken from 

the left side of the nose and extending in a curve towards the lower part of the left ear where 
its base was situated. The mucous membrane and skin which had become attached to the 
jaw on the right side were cut through their whole thickness and swung forward to form 
the right portion of the lip ; a relaxation suture was inserted between the two, as very 
considerable tension was observed on the left skin-flap. The whole operation was done 
over an artificial denture and chin. Result : a considerable portion of the end of the left 
flap sloughed, and a triangular space on the left cheek was left uncovered, as well as the 
lower portion of the wound. 

Operation. February 28th, 1917, to close circular opening below lower lip, left from 
sloughing of flap after last operation. The opening was surrounded with scar tissue, which 
was removed (as in fig. 303). 

13.6.17. Operation (Captain Gillies). Incision below mandible. Exposure of ends 
of fracture. 

Graft was taken from the right seventh rib. A hole was drilled in the right fragment and 
a peg of bone on left fragment was shaped to carry the graft. The splint was very stiff, 
and it was found very difficult to immobilise the fragments. This mobility resulted, un- 
fortunately, in breaking off the peg on the posterior fragment, and the graft was not therefore 
fixed into the bone on the left side. 

6.1.18. Upper denture fixed. There is some movement between two fragments of 
jaw. X-ray shows the graft apparently united at one end. 



Fio. 298. Early condition. 

FIG. 299. Healed condition. 

FIG. 300. First plastic : Outlining of flaps. 

FIG. 301. First plastic : Suture. 



Fid. 302. Result of first plastic. 

FIG. 303. Second plastic : Excision of scar. 

FlO. 304. Second plastic : Suture. 

Fid. 305. After final plastic. 



Injuries of the soft tissues of the chin below the lower lip do not visually 
require more than excision of the scar tissue, in the usual manner. 
The following two cases, however, have special interest : 

CASE 32 

This case has a photographic record of his early condition, but not one when it was 
healed. The mandible united after the comminuted fracture present about ten weeks after 
the injury and the external wound healed with a large depressed scar, adherent to the 
bone. He was wounded on 1.7.16, and the first plastic operation was performed three 
months later. After excision of the scar, a celluloid plate was inserted to raise the scar and 
to give the necessary contour, the plate being held in position by catgut sutures to the 
periosteum of the mandible. This operation was followed by continued small haemorrhages, 
and the celluloid plate was removed. Two months later the scar was re-excised, and a 
free fat-graft from the buttock was inserted. The result of this fat-graft was very successful, 
and gave an excellent contour. Whether any absorption has since occurred is not deter- 
minable, as the patient was discharged to duty a month after the graft. 

Fio. 306. Early condition. 

FIG. 307. -Final : Contour restored by free fat-graft. 



CASE 129 

Tliis case had large central loss of the soft tissues of the chin, which healed vip, with 
a puckered, depressed scar. There was some ectropion of the lower lip, due to the pull of 
the scar. 

The healed condition, prior to operation, is shown in fig. 309. It will be noted that 
there are considerable radiations of the scar extending upwards and downwards from the 
main body of the scar. 

However, excision was practised, and the resultant gap which presented itself for 
repair closely resembled that seen in fig. 308, which is that of the early effect of the wound. 

A difficulty thus presented itself somewhat unexpectedly, as the direct approximation 
of the two skin-edges was found to evert the lip considerably. A decision had to be made 
between the interposition of a flap between the two skin-edges or undercutting very freely 
a lower flap and suturing it to the chin with deep catgut. The latter procedure was the one 
adopted, but although this was markedly improved there was some eversion of the lip 
remaining, in addition to a smaller scar than hitherto. 

In reviewing this case, there is no doubt that it would have been better to have employed 
a flap. There is always considerable difficulty in undercutting the tissues of the chin, and 
the greatest benefit is to be obtained in this region by carefully sewing up the lower flap by 
catgut to the periosteum overlying the mandible. 

The reason for showing this case, which is an indifferent result, is to bring forward the 
difficulties one experiences in this particular region. 

Flo. 308. Early condition. 

FIG. 309. Healed condition. (Stain due to 



FIG. 310. Excision of scar. 

FIG. 311. Suture. 


FIG. 312. Indifferent result (see text). 



CASE 139 

This is published, although an unfinished case. It is shown as an attempt at restoration 
in that not uncommon class of gunshot wound of the jaw in which the whole body of the 
mandible and the soft overlying tissues have been blown away en masse. The photograph 
of this patient, taken soon after admission, sufficiently explains the extent of the lesion. 
It is an interesting point to note that this gallant fellow walked several miles to the dressing 
station on July 4th, 1916, during the battle of the Somme, and this very feat of endurance, 
maintaining, as it did, the upright position, may have prevented an emergency tracheotomy 
or even a worse fate. The loss of the lower lip and tissues of the chin is complete, while 
the amount of mandible remaining is represented by the thinned and atrophied ascending 
ramus of the right side, and by the ascending ramus, angle, and one molar tooth on the left. 
The condition in January 1917, after the healing process was complete and the general 
condition more satisfactory, is shown in fig. 314. 

FIG. 313. Early condition. 

Fio. 314. Healed condition. 

At this stage the first operation, which took place on February 27th, 1917, was performed 
under chloroform-oxygen anaesthesia in the sitting-position, administered by Lieutenant 
R. Wade, R.A.M.C., at the Cambridge Hospital, Aldershot. The main features of the 
operation were the freeing of the tongue and the making of the flap which formed the basis 
of a new lip. The result, as far as it went, was satisfactory, as shown in fig. 318, but the 
absence of the mental prominence as well as the loss of function, were left to be dealt with 
until a later stage. 

A serious attempt to bulge out the new " lip " by traction from a head-piece was made 
in conjunction with Captain W. Kelsey Fry, M.C., at the time of this operation, but it was 
badly tolerated and the result was not gratifying. In view of the general shortage of tissue, 
plastic flaps from the neck or cheek were not indicated, and in view of the success of the 
double-pedicled imbedded flaps and of the experience one has had of single-pedicled bridge- 
flaps, it occurred to me that the employment of a double-pedicled bridge-flap from the scalp 
would meet the case without fear of the blood-supply. By a bridge-flap is meant one in 
which the pedicle lies over healthy skin, is divided from the grafted terminal portion after 


about ten days, and is then replaced into its original position. The double-bridge flap, 
though I believe original, is merely the logical development of double-pedicle imbedded 
and single pedicle bridge-flaps, and it combined the advantages of a double blood-supply 
and of the provision of a flap well distant from the lesion. 

In this particular operation, which took place on September 20th, 1917, at the Queen's 
Hospital, Sidcup, Captain J. L. Aymard and Lieutenant G. C. Birt assisting, in which ether- 
oil was given by the rectal method (Lieutenant R. Wade), the flap stretched from ear to ear 
across the vertex and was about 3 inches in width. See fig. 320. Before bringing this into 

Fio. 315. Showing amount of mandible lost. 

FIG. 317. Stages in first plastic. 

Fio. 316. First plastic : Freeing of tongue and advancement of 
flap as beginning of new lower lip. 



position, the skin below the buccal opening was raised by incision and dissection, and laid 
on the upper surface of a large osteo-chondral graft from the seventh rib. This measured 
some 6 inches along its long convex border, and was the shape of a boomerang ; it included 
about 1 inch of the bony portion of the rib and was fixed by iron wire into the remains of 
the jaw, bone to bone on the left side and cartilage to bone on the right, being fixed so that 
the point of maximum convexity of the cartilage became the prominence of the chin. The 
large scalp-flap was then swung over the face into position so that it covered the upper, 
lower, and lateral aspects of the new " jaw," and sutured to the surrounding skin edges. 

FIG. 318. After Brat plastic. 

FIG. 319. Second plastic : Scalp flap on double 
pedicle swung down over bone graft. 

The pedicles were cut on the eleventh day and returned to the scalp (fig. 321) ; the new blood- 
supply of the grafted portion being satisfactory, there was no question of gangrene. 

Many causes operated against asepsis, of which the more obvious were : (1) the length 
of operation ; (2) the difficulty of sealing off the junction of the pedicle and the imbedded 
portion ; and (3) the very strong growth of hair on the flap. Discharge appeared at the 
lower border of the flap on the fifth day, and has continued. 

One must own that, in planning this operation, it was not expected that a good functional 
result would accrue, but some degree of mastication is possible where there was none, and 
the gain to the patient of having a chin and a full beard is almost certainly permanent. The 
secondary disability is a bare area on the top of the scalp, which is being epithelialised. 

In criticising this procedure the author feels it would be better either to insert a piece 
of metal or celluloid at the time the scalp-flap is brought down, to be replaced later by an 
osteo-chondral graft under more aseptic conditions, or else to imbed the graft in two halves 
in the scalp some six weeks before it is swung down. In this event, the graft, at a later 
stage, could be joined in the middle and to the remains of the jaw. 

The cartilage graft, with its small attached portion of bone, continued to undergo 
absorption from suppuration, until it had all absorbed. The wires and the sequestrum 
were removed in February 1919. 

The appearance now was very much inferior to that when the graft was giving shape 



to the chin, and the portion of scalp which had been grafted there had undergone a con- 
siderable amount of wrinkling. The patient refused to grow a beard, which might have 
camouflaged the defect, and unfortunately depilatory doses of X-rays were applied. This 
led to a partial depilation only, and the resulting appearance of islets of hair surrounded 
by white, lifeless-looking skin was a further disappointment. Since then two attempts 
to remedy the man's condition have been made without any success ; and a third attempt 
is in progress. But the general condition, lowered by the results of the injurv and long 
period under hospital treatment, is such that the prospect is not very hopeful. 

FlQ. 320. Second plastic : lateral view. 
(Note pedicle.) 

FIG. 321. Pedicles severed and returned. 


CASE 76 

This case was received in my clinic only three months after being wounded. 

This patient, though not giving such a ghastly appearance in the early photograph 
as the previous one, suffered a greater loss both of the bone and of the soft tissues. The 
whole of the upper lip and the whole chin had been swept away, and the tongue was adherent 
to the margin of the wound. The loss of bone in the mandible is very extensive, being, 
however, just in front of the angle. 

Three months after wound the first plastic was done. The dental officer in charge of 
the case was Captain Hornyblower, working under Captain L. A. B. King, R.A.M.C. A 
large vulcanite artificial chin was made and attached by a splint to the upper teeth, and 
an attempt was made to make the new mouth over this. 

The result was indifferent, and no attempt to remake the chin was carried out. 

Had it been possible to have retained the appliance, a satisfactory mouth might have 
eventually been obtained, but the swinging in of the flap on the left side had pulled over 
the corner of the mouth to a very considerable extent. When all had healed up there was 
considerable tension of the new lip, and, after consultation with the dental surgeon, it was 
decided to remove the prosthesis. When this was done, it was thought necessary to close 
the lower opening in order to prevent the dribbling. 

The intermediate stage photographic records are missing. It consisted of the widening 
of the mouth to the left, so that access to the buccal cavity could be obtained by the dental 
surgeon, Captain W. Kelsey Fry, M.C., R.A.M.C., working in conjunction with Sir Francis 
Farmer, who designed an appliance, next attempted to stretch forward the tissues of the 
chin, which had now become softer and more amenable to traction. The patient, however, 
was not particularly tolerant to this procedure, and I felt that perhaps one was wasting 
time, and, after consultation with Sir Francis Farmer and Captain Fry, who advised one to 
carrv out a more radical procedure for the building up of a new chin, the author obtained 
from Lieutenant W. W. Edwards, the sculptor, a kind of chin in plaster, the size of a pros- 
thesis necessary to make a chin over it. This was later cast in aluminium, and attached 
by suture to the upper teeth, on which was a cap-splint. Around this artificial apparatus 
was built an epithelial pouch, in the following manner. Three skin-flaps two being lateral 
and one central from below were reflected and sutured, with continuous catgut, over the 
middle raw surface outwards. These flaps were accurately designed beforehand in tinfoil. 

The raw area thus created by the turning in of these skin-flaps, which included the 
prominence of the new chin, was also accurately gauged beforehand, and a model cut in 
rolled-out lead plate, to which were added the necessary pedicles, to carry a large double 
pedicle scalp-flap down to the chin. The appearance of this flap is shown. 

It all healed by first intention, the pedicles being carefully attached sewn skin-edge 
to skin-edge. 

The central portion of the scalp was skin-grafted, the Thiersch grafts being taken from 
a tattoo mark in his right forearm, the idea being that the blue tattoo mark would show 
less conspicuously than white skin. It is interesting to note that this mark contained the 
letters " Bert," and up to the time of writing, which is six months after the operation, 
the letters are still quite clearly legible on the top of this patient's scalp. The pedicles 
were returned under local anaesthesia without difficulty, one of them being done for me by 
Captain Waugh, U.S., M.R.C., and in the main operation I had the assistance of Major 
Dorrance, U.S., M.R.C. The effect of this operation is to have produced an epithelial pouch 
on the front of the man's neck. The back wall of this pouch is lined by the previously 
existing lower margin of his mouth, which was not destroyed. It is intended to divide this 
inner partition, to spread it along the margin of the new lip as a red margin. This will have 
the effect of making the two cavities into one, and Sir Francis Farmer has taken a cast 
which indicates these two cavities as they exist at present. It is intended to fit a combined 
chin and lower denture to the remains of the mandible. No crinkling or retraction of the 
grafted scalp-flap is occurring now three months after the operation and a satisfactory 
beard could be easily grown. The patient, however, prefers to shave. 



FIG. 322. Healed condition : Front. 

FIG. 323. Healed condition : Profile. 

FIG. 324. After first plastic. 

FIG. 325. Scalp flap on double pedicle brought down 
over inturned skin flaps from cheeks and neck. 



Fio. 326. 

FIG. 327. 

FIG. 328. 
After return of pedicles : Front and side views. Prosthetic chin in position. 


Remarkable further progress has been made in this case in that into such a plastic chin 
containing no musculature a new mandible has been successfully grafted. Also see opera- 
tion notes. X-ray of the bone-graft is too late for insertion. 

An excellent functional result has been obtained. 


Gunner W , wounded France, 16.9.16, admitted 30.9.16. G.S.W. 2, 4, 8, 1, 9, 1. 

Fracture through both horizontal rami just in front of angles, whole of intervening jaw 
missing. On right side there are stumps remaining of M. 2. Left side M. 2 is involved. 

4.12.16. Plastic operation (Captain Gillies). The main feature of this operation in 
the attempt to form the mouth was that a local flap cut from the right cheek with its base 
upwards, was swung down and placed over a large prosthesis and made to meet the whole 
thickness of lip which remained at the left angle of the mouth. This was cut in a circular 
fashion about half an inch from its mucous border to enable it to swing forwards. No 
attempt was made to close over the large gap below. No relaxation sutures were used other 
than catgut and deep silkworm in the flap itself. 

8.3.17. Operation (Captain Gillies). A flap dissected up from left upper lip of cloaca 
with its base at level of angle of mouth, inner edge being about 1 inch distant. Mucous 
membrane along floor of mouth united to that lining edge of cloaca or region of flap. The 
under surface of tongue was freed from the adhesions binding it down to floor of mouth. 
Two strong silk-worm gut ligatures passed through substance of tongue and tied over metal 
bar of bridge fixed on upper teeth, thus lifting the organ and preventing formation of further 
adhesions. Skin freed along remaining upper lip of cloaca, freshened inner part of lip 
twisted upon itself and sutured to base of tongue. Lower lip of cloaca freshened. A flap 
raised by taking incision from the outer third of lip downwards and outwards to the right 
neck at about the level of angle of mandible. Remaining portion of cloaca edge on left 
side freshened and undercut, deep catgut retention sutures being used for anchoring the 
large flap into its new position. Skin surfaces united with horsehair, thus entirely closing 
cloaca. A vulcanite splint was fixed in position along floor of the mouth by means of sutures, 
in order to supply contour over the chin region. 

21.6.17. Small plastic operation on lip to enlarge mouth. 

7.10.17. Transfer to Park Hospital, Hither Green. Scarlet Fever. 

14.12. 17. Readmitted. 

11.5.18. Operation (Major Gillies) for new chin and lower lip. 

Method. Model of inside measurements of new chin made in cast silver and laid 
over existing aperture (designed with the assistance of Lieutenant J. Edwards) and suspended 
from the upper teeth. Over this chin-piece three skin-flaps (two lateral and one inferior) 
were sewn over their skin surfaces towards the prosthesis which now lay in a complete 
epithelial pouch. Sutured by catgut, with assistance of Captain H. C. Malleson, R.A.M.C., 
and Major Dorrance, M.R.C., U.S.A. The raw surfaces from which these flaps were taken, 
as well as that which lay over the chin, were covered in by a double-pedicle scalp-flap, which 
was swung over the face into position. In cutting the pedicles of this flap care was taken to 
cut and ligature both the anterior and posterior branches of the temporal artery, so that the 
main force of this blood-vessel should be directed into the pedicle. Both the inturned flap and 
the scalp-flap were accurately cut to previously designed models and all fitted accurately. 

Skin graft thigh to scalp, partial, and also tattoo-mark in arm transferred to same area. 

Later. An osteo-periosteal graft from the tibia, seven inches in length, was wired 
to the mandibular remains in September 1919. Healing was by first intention. The appear- 
ance has not been altered. 

Bony union has occurred at both ends, and a functional dental appliance fitted over 
the new mandible, giving from 50 to 60 per cent, of normal mastication. 

Figs. 329 332 illustrate a modification of the method of forming a chin used in 
Case 76. It has been employed in two cases, both of which are as yet unfinished but 
give every promise of an excellent result. 



Fio. 329. Flaps for lining of new chin outlined. 

Fia. 330. Lining flaps being inturned over a 
prosthetic chin. Forehead flap outlined. 

Fio. 331. Covering flap for chin being swung 
down from forehead. 

Fio. 332. Suture. Pedicles tubed. 



The reconstruction by bone of the missing portions of the mandible is the 
ultimate aim in the great majority of severe injuries of the lower lip and mandible. 
In quite a number of cases there is a much larger loss of bone than of the soft 
tissues. These present no difficulties, and the operation for bone-grafting is 

It is not proposed, in this volume, to enter at all fully into either the theory 
or practice of this procedure. A rough outline of the principles is indicated 
below, and the various methods that the author has adopted, or seen adopted 
in his actual experience. The author was very strongly opposed in the first 
two years of his experience to the use of any foreign body, such as wire or plates, 
as a method of fixation. In this he was influenced by the work of Albee and 
Lindemarm. In the early stages, the operation of bone-grafting was very 
much on trial, and in these early days many cases were operated on too soon 
after the healing of the wound, and frequently in tissues which were not suffi- 
ciently vascular to tolerate the graft. The method of auto-fixation which was 
adopted was exceedingly difficult, but a large number of cases of successful 
rib-grafts were obtained in 1916 and beginning of 1917. The method of auto- 
fixation was, broadly, the making of a hole in one' fragment and a peg on the 
other fragment fit respectively into a hole and a peg of a graft. When this 
fixation was satisfactory, the cases were most successful. Several of these 
grafts have been examined two years after their insertion, and the function- 
when the dental condition allows it is remarkably good. 

One officer who had two inches of rib inserted (fig. 337) can crack a brazil- 
nut. Owing, however, to a certain number of disappointments inseparable 
from this method such as the breaking of the peg or of the fragment at the 
last moment of the operation a number of these grafts failed, the graft being 
absorbed, either by sepsis or aseptically. 

Concurrently with this method the author adopted the osteo-periosteal 
method advocated by French surgeons, but reserved it in the first instance for 
gaps of small dimensions. The method was gradually extended to larger gaps, 
and in the author's opinion it is specially suitable for grafts : (1) in newly made 
soft tissues ; (2) in very large gaps round corners where one fragment is prac- 
tically non-existent while the other is fixable by splints ; (3) where the fragments 
can be maintained in position by dental splints that is to say, they bear sound 
teeth which can be utilised for intra-oral fixation ; in this case the gap may 
be quite short, as in a pseudo-arthrosis, or qviite large, as where the bone is 
quite lost from molar region to molar region, a tooth remaining on each fragment, 



It is also claimed by the French that this method can be utilised at a much 
earlier date than a block graft. The author dissociates himself from this view 
as he thinks it is unsound, although not disputing the possibility that osteo- 
periosteal graft more readily forms bone in a septic wound than do the block 
grafts. In all cases, a due interval should be allowed to elapse ; this interval 
varies according to the condition of the tissues into which the graft has to be 
placed and to the length of time that the case has remained septic after the 
wound. The author is convinced that this method has a definite place in the 
methods to be chosen for special cases. 

Still adhering to the principle of auto-fixation, the author went to the 
tibia for losses in the region of the angle of the mandible in which it is desirable 
to replace and maintain the posterior fragment as far back as possible. In 
order to do this, specially shaped blocks of tibia were laboriously fashioned to 
make an accurate reconstruction of the angle and missing portion of the body 
of the bone. On the posterior end of the graft was usually left a peg of bone 
which was fitted up a canal made in the medullary cavity of the posterior frag- 
ment. The anterior fixation Avas made by similar but smaller wedging or by 
a bone-peg. The X-ray of two such examples is amongst the series shown. 
The method is very interesting, and exceedingly good when successful. It is, 
however, much too difficult to perform, and requires an operation lasting some- 
times over three hours. The graft also has to be handled considerably in order 
to make it fit accurately. Other disabilities of the method are that accidents 
with the graft are liable to occur in taking it from the tibia, and in several cases 
the shaped graft after its removal from the tibia --was split at some part. 
Two good examples are shown in figs. 346 and 348. A third is shown in fig. 350 : 
in this, however, the shaped graft, taken from a brittle tibia, broke twice before 
its shape was complete. In fitting in the remains into the recesses made for 
it in the fragments, the fragments broke. As a last resort the graft, now whittled 
down to a thin plate of compact bone, was wedged into the fragments at each 
end and retained there by a silver wire passed from one fragment to the other 
without passing through the graft. The result was strikingly good, a most 
solid bony union occurred despite the various disasters that had happened. 

The pedicle bone-graft, as advocated by Cole, was adopted in a certain 
number of cases, one or two examples of which are shown in figs. 352 and 354. 
The operation is easy to perform, is not liable to sepsis, and is a method of choice 
for certain types. It would, however, appear to have no real advantage over 
the plain block-graft from the ilium. Its disadvantages would appear mainly 
to be : (a) that the union is liable to be springy as it occurs only along the lower 
border of the mandible and no regeneration of the bone-tissues of the alveolar 
portion occurs ; (b) if used in large gaps one is apt to get insufficient apposition 


of good bone between the graft and the mandible ; (c) cosmetic-ally, it is in- 
different ; (d) a query is also raised as to whether the taking of the lower border 
from the healthy part of the mandible may not unduly weaken that portion, 
especially when absorption of the alveolar bone occurs after the teeth come out. 

It is a very easy operation to perform for a loss of bone occurring in the 
middle of the body of the mandible ; but its advantages even in this simple 
type of case do not outweigh its disadvantages, and it would not appear to give 
better results than the straight ilium block operation. 

For large gaps, Lieutenant-Colonel H. S. Newland, D.S.O., A. A.M. C.,' had 
advised the use of combined pedicle and block-graft. A small pedicle bone- 
graft is fixed to the main graft in the centre of the gap with the idea that the 
osteogenetic process should commence in the middle as well as at the end of 
the graft. The principle seems sound, and is an improvement on the Cole 
pedicle graft, in that it regenerates bone not only along the lower border but 
also up towards the alveolus. 

The next stage in the hisbory of bone-grafting was the use of block tibia 
and ilium grafts of simple character, wired into position between the frag- 
ments. The adoption of this method by the various surgeons in the Queen's 
Hospital, Sidcup, was generally due to Sir Arbuthnot Lane. It is so simple 
and successful that little interest remains in the operation, and provided that 
no concealed sepsis is lit up by the operation, .110 cases of failure to obtain 
bony union are now reported. 

The Author's Method. Indications : where the loss of bone includes the 
whole of the ascending ramus, such as occurs after excision of the mandible 
for tumour. A piece of the seventh or eighth rib taken from the opposite 
side, including the costochondral junction and the point of maximum convexity. 
The bony portion of the graft is wired to the freshened anterior fragment. The 
maximum point of convexity forms a new angle of the mandible, while the 
ascending ramus is represented by that portion of costal cartilage which runs 
upwards to the sternum. A false joint in the neighbourhood of the glenoid 
fossa is thus made, and a cosmetic and functional result accrues (figs. 333-335). 
The author also undertook a number of bone-slides where attempts were 
made to interpolate partially or completely detached pieces of bone from the 
end of a fragment into the gap between the two. 

A few of these were successful, but the majority ended in non-union, owing 
to the fact that insufficient freshening of the eburnated ends of the fragments 
had been made. 

A simpler method than this has been adopted by Billington. The surfaces 
of the fragments are freshened and a split rib laid over the gap and the two 
fragments with a considerable overlap. The soft tissues are merely sutured 


over this m-aft. When all is healed, the case is handed to the dentist, who 


fixes the necessary splint. In all previous methods the mandibular fragments 
are fixed as far as possible in a correct position prior to operation. Billington's 
method has the virtue of simplicity, but can have no place as a method of 
controlling the edentulous fragment. 

It is practically agreed that the posterior fragment, when once it has swung 
forward, which it does in the vast majority of cases, cannot be controlled satis- 
factorily by any intra-oral method. The pressure of the apparatus necessary 
to do so, in my experience, invariably causes pain, discomfort, and ulceration 
of the mucous membrane over the ascending ramus. In such cases it is essential 
to insert a block of bone which will, by its length, press back the posterior 
fragments. Adequate fixation, either by wire or wedging, must also be provided, 
so that the posterior fragment is maintained there. 

Summing up the present position of bone-grafting of the mandible, 
therefore : (1) The main source of bone should be the ilium. The fragments 
of the mandible should be maintained in their normal positions either by 
intra-oral apparatus, or by the graft. The method of fixation of a block-graft 
should be by wire. Some degree of auto-fixation on the edentulous displaced 
posterior fragment is desirable. Union is more rapid when the graft overlaps 
the fragments either on its inner or its outer aspects. (2) The osteo-periosteal 
graft is indicated in very large gaps, in very small controlled gaps, and in 
tissues the blood-supply to which is poor. It is also useful for bony losses in 
the symphysis region where a marked curve is required. (3) Pedicle graft 
(Cole), combined with a superimposed block-graft (Newland), is an alternative 
and a very sound method of the plain ilium graft. (4) Billington's late fixation 
method no doubt has a place in cases where loss is minimal and where there 
is but slight and easily remediable deformity ; but the many late results of 
this method seen by the author do not encourage one to adopt it as a routine. 
(5) The autologous osteochondral graft (author) has not a large place in war 
injuries, but is the only method yet evolved to cope with the condition resulting 
from the removal of half the mandible in civil practice. In one such case its 
adoption has resulted in a marked cosmetic improvement, and also a small 
improvement in function due to the provision of an extra point d'appui for the 
symphysis. Explanatory diagrams are given. 



Fio. 333. The defect. 

FIG. 334. The opposite eighth or seventh rib 
the sourco of the graft. 

Fio. 335. Graft in position. 


The skiagrams which follow arc selected from among a very large number 
of cases as being fairly typical of the various methods discussed in the preceding 

For the most part they require no description, the condition being in each 
case evident to the practised eye. 

After there is firm union it can nearly always be made possible to fit a 
denture, by employing the author's modification of the Esser Inlay operation 
to recreate the labiogingival sulcus, as described in the chapter on Principles. 
This was achieved even in Case E, though here, as is usual in such terrible cases, 
the denture is a cosmetic rather than a functional triumph the paucity of 
teeth precluding any attempt to fit a masticatory appliance. 

No example is shown of an osteochondral graft, as the major portion of 
the graft, being cartilaginous, throws no shadow, and the skiagraphic appearance 
presents nothing peculiar to this method. 


Fio. 33G. Case A. (Rib graft.) 

Fio. 337. Case B. (Bib graft.) 

FIG. 338. Front. F IG . 339._Lateral. 

Case C. Osteo -periostea! graft from tibia. 



Fio. 340. Case D. (26.8.18). 

FIG. 341. Case D. (7.11.18). 

FIG. 342. Case D. (7.11.18). 
Osteo-periosteal graft from tibia. 



FIG. 343. Case E. (1.10.18). 

FIG. 344. Caso E. (7.7.19). 

FIG. 345. Caso E. (7.7.19). 
Oeteo-periosteal graft from tibia. 



Fid. 340. Case F. 
(The oivli of tho fragments are outlined with dots.) 

FIG. 347. Case F. (Tibial Block.) 

Fio. 348. Case G. Tibial Block. (12.2.18.) 

FIG. 349. Case G. Tibial Block, (10.12.18.) 


Fia. 350. Case II. Tibial Block. (20.0.18.) 

Fio. 351. Case H. Tibial Block. (3.7.19.) 

Fio. 352. Case I. (8.8.18.) 

FIG. 353. Case I. Pedicle graft. (15.11.18.) 



FIQ. 354. Case J. (14.8.18.) 

FIG. 355. Case J. Pedicle graft. (18.12.18.) 

Flo. 356. Case K. Lateral. (14.1. 18.) 

Fio. 357. Case K. Ilium Block. (14.11.18.) 


Fio. 358. Case L. Major Chubb's case. 

FIG. 359. Case L. Ilium Block. 

Fio. 360. Case M. Ilium Block. 



IN the treatment of injuries of the face, with laceration or destruction of the 
soft tissues, with or without loss of the bone, it is the aim of the plastic suigeon 
to replace the tissues to their normal position and so restore the contour of 
the face. When these injuries involve the tissues of the oral cavity with con- 
sequent loss of teeth, the surgeon has the additional aim, in his treatment, of 
maintaining the mouth in such a condition that the patient will later be able 
to wear a functional denture. In the attainment of this aim in the treatment 
of many of the cases, the surgeon has a valuable aid at his command in the use 
of prosthetic appliances that is to say, mechanical means of maintaining the 
hard tissues in their correct alignment. These prosthetic appliances are usually 
made by a dental surgeon working in the closest. co-operation with the plastic 
surgeon, and it must be borne in mind that the appliances, to fulfil their objects 
successfully, should be of simple construction, removable as far as possible, easily 
kept clean by the patient, and in some cases of value in mastication as well. 

The appliances which may be of service are so numerous and varied that, 
for the purposes of description, it is necessary to classify according to regions 
the injuries which necessitate their use. 

1. Those involving the oral cavity ; 

2. Those involving the nose ; and 

3. Those involving the eyes. 

Injuries involving the oral cavity are frequently complicated by fractures 
of the maxilla or the mandible, with or without loss of bone, but it is not intended 
here to describe the treatment of such fractures except as they affect the work 
of the plastic surgeon. It is advisable that this class be further subdivided 
as follows : 

(a) Without loss of bony tissue, and 

(6) With loss of bony tissue. 

(a) In dealing with cases in which there is no loss of tissue, the main object 
of the prosthetic appliance is to maintain, in their normal positions, such parts of 
the hard or soft tissues as may have been displaced by the injury, and to prevent 
the gradual obliteration of the dental sulcus by adhesions, the latter object 
being of the greatest impoitance in the future fitting of dentures. 

13 103 



fragments of hard tissue are brought into alignment and the 
eonouaincS by means of a simple dental splint, sin .lar to^ ho 
in fig. 361, and when these cases involve laceration of the soft 

FIG. 361. Simple dental splints. 

are likely to obliterate the dental sulcus, removable vulcanite flanges are fitted 
to the splint, as shown in fig. 362, to prevent the soft tissues encroaching upon 
and destroying the sulcus. When there is only laceration of the soft tissues 

a similar appliance or a denture with exaggerated 
flanges is used for the same purpose. 

There are many variations of the use of 
flanges attached to splints or dentures ; the 
upward support of a lacerated and drooping 
upper lip may be taken as a typical example. 

A distinct type of case sometimes met with 
j s that of a marked deformity of the upper part 
of the face, but without loss of bone, due either to a complete horizontal 
fracture of the maxilla with a backward displacement, or to a complete 
vi-itical fracture with overlapping of the fragments, resulting in the falling in 
of the soft tissues, which gives the appearance, on a casual examination, of a 
case with loss of hard tissue. To restore the contour of the face, it is necessary 

Flo. 362. Splint with flange to preserve 

dental sulcus. 



to reduce the deformity of the hard parts, and for this purpose an apparatus 
first used by Major Rishworth, N.Z.U.C., has proved of great value. This 
appliance, as shown in fig. 863, consists of a headpiece attached by two vertical 
bars to a splint on the teeth of the mandible, the latter being fixed in the slightly 
open position. A splint is also fixed on the displaced fragment of the upper 
jaw, and the necessary forward tension is produced by means of screws attached 
to the vertical bars. In some such cases of overlapping, it is advisable to reduce 
the displacement surgically, and to 
hold the fragment in good alignment 
by means of simple dental splints. 

When there is only a loss of the 
soft tissue of the lips, etc., the neces- 
sary prosthetic appliance consists of a 
dental splint carrying a removal flange 
moulded in such a way that the plastic 
surgeon is enabled to build the new 
lip over it, maintain the correct con- 
tour, and form a new dental sulcus. 
In cases of extensive loss of the soft 
parts of the cheek, it is not only neces- 
sary to make a flange over which to 
build the soft tissues, but the jaws 
must be fixed in the position of the 
open bite, to prevent any trismus re- 
sulting from the contraction of the 
scar tissue. 

(b) In many instances there is a 
loss of hard tissue in addition to that 
of soft tissue, such as the loss of the 
pre-maxilla. This loss must be replaced 

by a prosthetic appliance as shown in fig. 364, for the purpose of maintaining the 
remaining bony tissue in its correct alignment, and to enable the surgeon to 
restore the soft tissue in its correct fulness and contour. When the loss of bone 
of the mandible is very extensive, the fragments are maintained as far as possible 
in their correct positions by dental splints while awaiting a bone-graft operation. 
This applies particularly to the posterior fragment, which if not so maintained 
will cause a marked deformity by the falling in of the soft tissues in the region 
of the angle. A dental splint is also worn during and after the bone-graft 
operation, to immobilise the fragments and graft and to preserve the teeth in 
good occlusion. For this purpose splints are fitted to the teeth of the upper and 

FIG. 363. Apparatus for forward replacement of 



lower jaws and fastened together with a screw or some such mechanical device. 
When there are teeth on both fragments of the mandible, no difficulty is ex- 

FIG. 365. Patient for whom the apparatus in pre- 
ceding figures was made. See also Case No. 62f> in 
section on Upper Lips (p. 87). 

Fio. 364. Prosthetic replacement of pre-maxilla. 

perienced in immobilising them. Such 
is not the case, however, when there 
is a small and edentulous fragment. 
Many attempts have been made to 
hold this fragment in position by 
means of a flange fixed to the lower 
splint, but the best results have been 
obtained by bringing down the pos- 
terior fragment at the time of the 
operation and fixing it by means of 
the graft. Early movement has been 
advocated and found efficient in these 
cases, and to facilitate this movement in instances where it is impossible to fix 
both fragments mechanically with a splint, it has been found of great value to 
have a guiding flange fitted on to the splint 
on the larger fragment, as shown in fig. 366, so 
as to prevent the tendency of this fragment to 
swing towards the smaller fragment, and thus 
put unnecessary strain upon the newly im- 
planted graft. By this means, movement can 
be started earlier than if the flange had not 
been fitted. 

With reference to the importance of pre- 
venting the encroachment of the soft tissue 
upon the dental suleus, and the consequent 
inability to fit satisfactorily a functional den- 
tare, many cases have come under notice in 



Fid. 3G7. Splint with flange to maintain Stent in position, 
for the Epithelial Inlay. 

which it has not been possible to prevent this encroachment during the early 
stages of treatment, and these cases for some time presented a difficult problem, 
which was exaggerated in many instances by the resultant falling in of the 
soft tissues. The first attempts to reform the sulcus were by freeing the soft 
tissues from the hard, and immediately fitting a splint or denture with an 
exaggerated flange to push out the soft tissues. The results of this method 
were far from encouraging, 
adhesions gradually taking 
place again. Recently, a 
more successful method has 
been evolved by the Tise of 
the epithelial inlay : opera- 
tion (modified Esser). For 
this operation a prosthetic 
appliance is required for the 
purpose of holding the Stent 
in position for the necessary period. As shown in fig. 867, this appliance 
generally consists of a metal cap splint with a removable horizontal flange so 
fitted as to maintain the Stent in position, and to keep it in close contact with 
the surrounding tissues to enable the epithelium to become adherent. In the 
after-treatment of these operations it is very important to remember that at 
no time should the newly made sulcus be left empty, and, after the removal 
of the Stent, a denture carrying the necessary prolongations must be immediately 
inserted, and should be worn continuously for at least three months, after 
which time experience has shown these results to be permanent. In the event 
of loss of hard tissue in these cases, the denture is made to carry excessive vul- 
canite to enable the soft parts to be restored to the normal contour. This 
would not be possible in many cases unless the sulcus had been reformed by 
an epithelial inlay, as the pressure exerted by the soft parts would make the 
denture unstable and functionless. 

Exaggerated cases of this type often present themselves. The extensive 
loss of the anterior portion of the maxilla having resulted in a considerable 
falling in of the soft tissues, a marked deformity of the profile of the face is 
caused. The following cases are typical : 

1. Private M 

. On admission, it was found that he had an old gunshot wound, 
with large loss of the maxilla and nasal structures and loss of both eyes. The hard palate 
was entirely lost except for a small part, which included the two posterior tuberosities with 
the intervening part of the palate. Both antra were widely opened, owing to the absence 
of the nasal and anterior walls. The soft tissues of the lip and nose were adherent to the 
small remaining part of the palate as shown in figs. 368 and 369. The case was seen by Major 
1 For details of Stent and Epithelial Inlay see pp. 10 and H. 



FIGS. 368 and 369,-Extensive bony loss. 

FIGS. 370 and 371.- Prosthetic replacement of loss, 



Gillies, who decided to free the soft tissues from the small remaining part of the palate. 
The anaesthetic was given through a laryngotomy tube. A knife was inserted behind the 

FIGS, 3 a and 373. Showing bony loss and prosthesis to replace it. 

upper lip, and the line of attachment of the soft parts, both to the hard palate and laterally 
to the remains of the superior maxilla, was divided 
in a vertical direction until the level of the eye- 
sockets was reached. The soft tissues were then 
stretched forward. At this stage the case was 
taken over by the dental department for the soft 
parts to be kept in the new position. With the 
patient still under the anaesthetic, dental com- 
position was forced up into the gap made and 
left to harden. When .hardened it was removed 
and the impression used for making the necessary 
permanent apparatus. In the meantime another 
piece of composition was inserted into the gap 
and left in position to hold the soft parts out while 
the apparatus was being made. In this case no 
epithelium was used to line the new cavity, and 
great difficulty was experienced in permanently 
maintaining the soft tissues in their position, and 
it was only after various mechanical appliances 
had been constructed to force the soft tissues 
forward that a happy result was obtained. 

2. Private P . This case was similar to 

the above, but the loss of bone was not so great 
(see figs. 372 and 373). The operation performed 
was similar, except that a small Thiersch skin- 
graft was placed upon the Stent, and round the 
orifice of the cavity made, the cavity itself not FIG. 374. Result of replacement. 


being lined. Here, again, great difficulty was experienced in keeping the soft tissues in 
their places, although not to such an extent, as in the former case. Fig. 373 shows the 
denture with a prosthetic replacement of the bony tissue lost. 

3. Lieutenant W . As in the case of Private M , there was a very extensive loss 

of bone. Before this patient came under treatment he had undergone repeated operations 
for closing off the oral cavity from the remains of the nasal cavities, which had been entirely 
Muvcssful. At the same time he presented the marked deformity shown in fig. 86 (p. 2C6), 
and it was impossible to reform the nose to a satisfactory result in that condition. Moreover, 

the fitting of a really functional denture 
was not possible. Judging from the ex- 
perience of the above cases, it was decided 
to reopen the passage between the mouth 
and the nasal cavities and replace the loss 
of bone by a prosthetic appliance. The 
operation performed was the same as in 
Case 1, except for the important difference 
that the whole of the cavity was lined by 
means of a skin-graft, the cavity pre- 
senting a white appearance due to the 
epithelial lining (vide fig. 375). The result 
was more than satisfactory, and at no 


time has there been any difficulty in 
keeping the cavity open. It is interesting 
to note that, with the passage of time, 
the implanted epithelium becomes pinkish, 
and approximates more and more closely 
to mucous membrane. 

These cases emphasise the fol- 
lowing points : 

1. The necessity of restoring 
loss of bone by a prosthetic appliance 
before attempting plastic operations upon the soft parts ; 

2. The great advantage of the epithelial inlay operation over the old method ; 

3. The great aid, in making a functional denture, of having a certain amount 
of support from the prosthesis replacing the lost bone. 

In none of the above cases was it possible for the patient to wear a denture 
before the operation had been performed. At present they are all wearing an 
efficient appliance. 

Fio. 375. Cavity lined by Thierscli graft. 


In the treatment of cases of laceration of the soft and hard tissues of the 
nose, with or without loss of such tissues, it is often necessary to restore the 
replaced tissues to their correct position by prosthetic appliances. The ap- 



pliances which may be used are 

very varied, but generally speaking 

are of two classes : 

(a) Intra-oral, using the teeth 

as the point d'appui ; or 

(6) Extra-oral, i.e., where a 

headpiece is used for purposes of 


Wherever possible, intra-oral 

appliances are preferable, owing to 

the difficulty experienced in obtain- 
ing complete stability by fixation 

to a headpiece and to the discomfort 

often caused by the pressure upon 

the head exerted by headpieces. 
(a) Intra-oral appliances. 

Fig. 376 illustrates a typical 

apparatus used to support the 

lacerated portions of the tissues 

after surgical replacement, which no. 370.-^! splint with dental fixation. 

has been found very successful. It should be remembered, however, that 

this appliance should not be used to exert pressure upon the soft parts, 

but merely for the purpose of supporting them in their correct positions. 

Too much pressure will only lead to ulceration, and failure will result. 

In instances where the bridge of the nose has been depressed, and the tip 

of the nose has been displaced upwards, the surgeon calls for an appliance to 

hold the nose in its correct position 
after it has been freed. Fig. 377 
illustrates a typical appliance used 
for this purpose. The piricer-like 
portion holds the columclla, and 
the necessary downward and for- 
ward pressure is exerted by means 
of attachment to a splint fixed to 
the teeth of the upper jaw. 

In cases of lateral displacement 
of the nose a very similar appliance 

FIG. 377 Adjustable nasal splint with dental fixation. ^ Q ^^ shovfn m fig> 377 is use d, 

pressure in these instances being exerted in the necessary direction by a vulcanite 
pad being placed either in the nasal cavities or on the external surface of the nose. 


Fio. 378. Adjustable nasal splint with extra-oral fixation. FIG. 379. Obstructed airway due to loss of columella. 

Fios. 380 and 381. Airway restored by prosthesis. 



(b) Extra-oral appliances. As mentioned above, this type of appliance 
is used only in cases where intra-oral appliances are not possible, owing to an 
edentulous or fractured upper jaw. 

Fig. 378 shows a type of appliance which was used to support the depressed 
bridge of the nose. The nose was 
surgically raised, two soft rubber 
plugs inserted in the nasal cavities, 
and attached to the appliance by 
means of silk brought out through the 
skin of the nose. Through a screw 
attachment pressure was brought to 
bear to hold the soft parts in the 
required position. This apparatus was 
elaborated for Major Gillies by his 
American colleague, Captain Ferris 
N. Smith, R.A.M.C. It will be noticed 
that the necessary support is obtained 
from three vulcanite pads, acting as 
a tripod upon the forehead and cheeks, 

thus obviating the discomfort caused by the wearing of tight bands round 
the forehead, and being a distinct improvement upon the Carter bridge system 
of support. 

In figs. 379, 380, 381, and 382 is shown how, in the absence of a columella, 
a prosthetic appliance can be fitted, which cariies out the double purpose of 
maintaining the airway and improving the appearance, without being unduly 

FIG. 382. The artificial columella. 


No prosthetic appliances are of any assistance in the early treatment of 
injuries in this region, except in cases where they are associated with fractures 
of the maxilla, involving the orbital plate. In these latter cases the maxilla 
is often displaced downwards, and the prosthetic appliance used for raising the 
upper jaw also supports the orbital contents, and tends to keep them in their 
normal position. 

When it is necessary to epithelialise the orbital cavity, a prosthetic appliance, 
as shown in fig. 383, is required to hold in position the Stent used in this operation. 
It consists of a vulcanite cup so shaped as to cover the Stent and hold it in 
position by attachment to a splint on the teeth of the upper jaw. After the 
removal of the Stent, it is necessary to make a vulcanite duplicate of it, and 



this also is maintained in position by the same appliance until such time as the 

artificial eye can be fitted. 

Cases are often found in which the plastic surgeon is able to reconstruct the 

soft tissues round the eye, so that the 
patient, who was unable, prior to the 
operation, to wear an artificial eye, is 
enabled to do so. But although he be able 
to wear the eye, it is sometimes impossible 
to reconstruct the eyelids, especially the 
upper, so that the eye bears the natural 
appearance. In these instances, a great im- 
provement can be effected by the construc- 
tion of an artificial eyelid, with eyelashes, 
attached to the artificial eye, which is held 
by the newly-made socket. It is also pos- 
sible, in some instances, to affix a ridge on 
the outer surface of the artificial eye in such 

Fia. 383.- Appliance used in epilhelialisation of a way that it will Support a dl'OOping Upper 

eyelid, and so enhance the cosmetic effect. 

Figs. 384 and 385 illustrate an apparatus (hardly prosthetic perhaps) used for 

protecting a recently-sutured palate from the movements of the patient's tongue. 

The above instances illustrate some of the valuable seivices rendered bv 

Fics. 384 and 385. Apparatus to protect sutures from patient's tongue after closure of palatal deficiency. 

prosthetic appliances in plastic surgciy, and the extensive and varied nature 
of such appliances. Ihe apparatus mentioned in this chapter are described 
as generally as possible, but it must be borne in mind that a critical consideration 


of the nature of the injury and the exact result aimed at is necessary in each 
case. Scrupulous care must be exercised in the adjustment of details, if the 
greatest possible benefit is to accrue from an appliance. Thus, there are many 
slight variations of the same appliance, each of which augments the utility of 
the apparatus in the successful treatment of injuries, similar in class but varying 
in detail. 

It must also be borne in mind that it is essential that there should be the 
closest co-operation between the plastic surgeon and the dental surgeon who 
is to make the prosthetic appliance. In most cases it is necessary to consider 
both the surgical and the dental aspects, and it is only by working together 
that the best results can be obtained. W. KELSEV FRY. 


Asa result of a study of a long series of cases treated in conjunction with 
Captain Kelsey Fry, M.C., R.A.M.C., and a development of the application of 
the Esser inlay principle, the author has come to the conclusion that the problem 
in palatal injuries can be much reduced. The essential problem here is the 
question of mastication : Is the condition of the parts such as permits the ap- 
plication of the most efficient dental appliance ? The author is convinced 
that the existence of abnormal oronasal communications is not a serious dis- 
ability ; it may even prove of immense service in the provisional support for 
a prosthesis. Provided that the perforation is accurately occluded by the 
appliance, it is found that the nasal cavity and antra are sufficiently protected, 
and that speech and deglutition are restored to normal. 

In one case of a perforation involving both antra, Captain Fry advised 
Major Seccombe Hett, under whose care the case was placed, to enlarge the 
perforation so that a purchase for the denture might be obtained from within 
the antra. The result was very satisfactory. 

Further to emphasise the supreme importance of the dental aspect in the 
treatment of palatal injuries, a case is quoted in which the author has actually 
re-created an oronasal communication which had been overcome previous to 
the patient's admission, with the definite object of furnishing support for a 

Lieutenant W- had sustained a total loss of nose and pre-maxilla (see 
also p. 200), and the palatal gap had been cleverly bridged in the remaking of 
the upper lip, which now hung from the anterior edge of the remnant of the 

It was not found possible to fit a functional denture. The first step, there- 
fore, was to free the lip from its new attachment. This led to a ringlike raw 



area, which was epithefialised by a Thicrsch graft held in position by moulded 
Stcnt fixed to a temporary appliance. Into the resulting intranasal prolongation 
of the buccal cavity a prosthesis was fitted, made in three pieces of vulcanite, 
and an efficient denture was made to take origin therefrom. An excellent 
functional result went hand-in-hand with a notable improvement in the ap- 
pearance (figs. 386 and 387). 

As in all facial injuries, a successful repair in this region depends on meti- 
culous care in the diagnosis. The loss in each layer of the palate, and the direc- 
tion of any displacement together with the factors which maintain it, must 
be accurately determined by oral, intra-nasal, and radiographic examination. 

FIG. 38f>. Soft tissues adherent to remains of 
palate after closure of oronasal communication. 

Fio. 387. Oronasal communication restored. 
Prosthetic replacement of bcny loss. 

These injuries bear a superficial resemblance to congenital deformities, but 
the problem is essentially different. There is actual loss of hard tissue, not 
mere failure of union ; and mastication, rather than speech and deglutition, 
is the first aim in repair. 

The first consideration, therefore, is the provision of a dental appliance 
which must not merely replace the structural loss, but should ensure efficient 

From the standpoint of treatment, these injuries may be divided as follows : 
1. Those involving chiefly the pre-maxilla and alveolar border. 

Ixperience has shown that these cases are, in essence, in the province of 
the dental surgeon. Certain important preliminaries may have to be completed 
by the plastic surgeon before the case is handed over. For instance, an adherent 


lip or cheek may require liberation with epithelialisation of the resulting raw 
area, before the dentist has any chance of fitting a masticatory appliance. 
Cases also occur where an ill-advised closure of a palate gap has been performed, 
and the surgeon is faced with the repellent necessity of undoing the good work 
of his predecessor, in order that the task of the dentist may be rendered possible. 

2. Injuries leading to large or small hard-palate perforations, which do 
not involve the alveolar border. 

Here the surgeon feels justified in attempting closure. The intact alveolar 
ridge gives promise of adequate support for any denture which may be indicated : 
there is no need of the mechanical advantage offered by the perforation. 

3. Lateral anterior defects involving the alveolus. Here the disposal of 
the case rests on the question of the existence of teeth on the fragments bordering 
the gap. If good teeth are present on both edges, closure may be undertaken 
in the knowledge that the dental surgeon has adequate support for the application 
of a masticatory appliance. 

If teeth are lacking a condition usually co-existent with a levelling of 
the alveolar ridge then there is need of any and every nook and cranny as 
possible purchase for the denture, and since mastication is the prime necessity, 
the surgeon must limit himself to the dental needs of the case. 

4. Injuries involving the soft palate. There need be no hesitation in 
repairing soft-palate injuries forthwith. The mobility of the part precludes its 
being of use as a point d'appui. 

Methods of repair used. So varied are these injuries in quantity and degree, 
that few methods, both classical and those hitherto unknown, have escaped 
a thorough trial, including at least two methods believed by the author to be 
original. Lane's double-flap method has given good results in the author's 
hands, where flaps have been available, and the Von Langenbcck principle 
has proved satisfactory in cases where the state of the parts permitted the 

The author has seen cases of successful results from the use of large mucous 
membrane flaps from the cheek. In selected cases, these would seem to be 

Working in conjunction with Major Seccombe Hett, the author has on 
several occasions made use of the inferior turbinate as a partial or complete 
obturator. This bone is separated from its attachment in part of its length 
and is swung down on the pedicle of what remains. 

Its double covering of mu co-periosteum makes it peculiarly adapted for 
the purpose, and its phenomenal blood-supply enables it soon to establish con- 
nection with the rawed edge of the palate. Its attached end can be safely 
severed in about ten days, and brought down to assist in the closure. 


The author has applied his tube-pedicle method in this connection, and 
large perforations have been closed with skin from the neck and chest by this 
means, in cases where coincident cheek loss has permitted the intrusion of the 
pedicle. Indeed, if need be, it is probable that there is no gap which could not 
be closed by this method. Were closure imperative, access for the pedicle 
could be obtained by temporarily enlarging the mouth. 

Summarising, therefore : First, a critical examination, with a view to 
accurate determination of the loss, then a consultation with the dental surgeon 
as to the advisability of surgical interference. (Shall the defect be covered, 
left alone, or even enlarged ?) And, finally, a consideration of the surgical 
possibilities of closure, bringing under review the approach to the injury, the 
flaps available, the viability of the parts involved. 




IT is not proposed to give a full historical outline of rhinoplasty. Noses have- 
been made since the very earliest times, and most of the methods possible 
and impossible have been tried on isolated cases. No one man has ever, 
previously, had sufficient material to elevate this branch of surgery from its 
unfavourable status, which has been so aptly summed up by the French in their 
saying " before he was horrible : now he is ridiculous." Artificial noses have, 
therefore, been developed to a far greater extent in the past than has the operation 
of rhinoplasty. How is it, then, that one is now in a position to state that in any 
given case of rhinoplasty it is probable almost certain that, following operative 
procedures, the patient will have a result that looks like a nose one that has good 
circulation, good colour, and a good airway ? The answer is manifold. 

The ravages of war have enabled a large number of cases to be collected 
under one team of surgeons. The various methods have been tried and sifted 
until a satisfactory combination has been developed. 

The great principle of providing all three elements of the nose skin, support- 
ing structure, and epithelial lining has been enunciated. In order to arrive at 
a satisfactory reconstruction, diagnosis must be made of the independent loss of 
each of these three elements. When it is known exactly what there is to replace, 
both in quality and quantity, the problem of the restoration becomes simplified. 
Among the following cases arc shown some good and some bad results. 
The first entire nose constructed by the author was lined with mucous membrane, 
without realising that it had been done. The next nose was made without 
such lining, and the unfortunate result led one to seek the cause of failure. From 
that day no nose, or portion of a nose, has been made here without its adequate 
skin or mucous lining, and the whole status of rhinoplasty, as practised by 
author and colleagues, has since that day undergone a change which is truly 
remarkable. Although the necessity for this nasal lining was recognised quite 
independently, one must pay great tribute to the rhinoplastic work of Kcegan 
in India. For the Indian type of mutilation (where an unfaithful husband or 
wife is punished by cutting off the soft parts of the tip of the nose) Keegan and 
his follower, Smith, designed exact inturned flaps to line the tip and the alae. 

The author had recognised that all noses must be skin-lined, but on digest- 
ing Keegan's written work one was absolutely convinced that this is the right 
principle. His particular flaps are applicable only to the loss of the lower third, 
or fleshy part of the nose. But the principle has been extended and modified until 
all types of loss can be successfully restored. Prior to this review of the Keegan- 
Smith operation, the author had been confronted with a very great difficulty in 
the " pug-nose : ' deformity. After several failures, one was fortunate enough 



to evolve a principle which not only produced a definite cure for this deformity, 
but is also applicable to many other restorations. This particular flap has been 
fully described in the chapter on Principles. So much for the lining membrane. 

In regard to the supporting structure, free cartilage implantations, both 
autologous and homologous, are freely used. The cartilage may be put in 
prior to the rhinoplasty, in either the external flap or in the internal flap, or 
it may be interposed between the two flaps at the time or subsequent to the 
rhinoplasty. The best time for such implantation varies with the type of case, 
but the author is convinced that the imbedding of the cartilage in the flap that 
is to make the external covering is an entire mistake. 

Occasionally the best result will be obtained by implanting the cartilage 

Fio. 388. Diagram to show the author's skin- 
cartilage awing to replace and retain the tip in position, 
and to provide skin-lining for the bridge and alse. 

FIG. 389. Position of the skin -cartilage flaps after 
they have been reversed. Tube-pedicle chest-flap is 
represented on its way to the nose. 

between the lining and the skin-flap at the time of rhinoplasty ; but the author's 
principle of imbedding the desired cartilage in the inturned flap seems the most 
scientific and best method. It is nearly always necessary to superimpose 
further cartilage at a later date. This must be done with great care, as on one 
occasion a very good nose was spoiled by unduly stretching the new skin. The 
other method employed by the author for obtaining supports is one which in- 
volves the grafting into the desired position portions of the septum or turbinates 
of the nose, and in certain cases much help is obtained from these transplanta- 
tions. Further, mechanical supports through an existing palatal orifice have 
been used by the author in syphilitic cases, after providing the other two 
necessary elements of the skin and lining membrane. 



The external covering presents fewer features of interest. It may be 
obtained from the arm, the cheek, the forehead, or from the chest by the 
author's pedicle. See figs. 389 and 390. From these methods the best-looking 
nose is undoubtedly that which is made from the forehead skin ; the sebaceous 
and greasy nature of the skin, together with its colour, render it more like nasal 
skin than that from any other part. Recently, an attempt has been made to 
provide the skin covering by a whole-thickness free-graft taken from the inner 
side of the arm ; but, although this procedure is not yet completely proven to be 
a successful method, it seems certain that it will shortly be an established prin- 
ciple. In the author's opinion, an exact pattern of the raw area to be covered 
should be made of tin-foil and the flap from the forehead cut exactly to shape. 

FIG. 390. Rhinoplasty from chest, author's tube-pedicle method 

The tin-foil model is made a little smaller than the raw area in order that the flap 
should be on natural tension. One has seen a great number of constructed noses 
the fat and clumsy appearance of which is, in my opinion, due to cutting the flap 
larger than necessary, to " allow for contraction." One's opinion is that no 
contraction can occur if the correct skin lining and supporting structures have 
been provided. 

The treatment of stenosis of the anterior nares, due to imperfect rhinoplasty, 
has been successfully dealt with by means of the Esser epithelial inlay. Many 
other types of stenosis are present as a result of gunshot injury. When the 
author undertook the problem of complete rhinoplasty, his first ambition was 
the production of noses which had an absolutely clear airway. Consequently, 
many operations are frequently necessary to clear such airway before the 


reconstruction is commenced. The principle of sewing skin to mucous membrane 
round the margin of an aperture is a very sound one and prevents contraction. 
The method of dealing with the restoration by means of a " Vallancey swing," 
has the inestimable advantage of giving such access to the nasal cavity that 
the debris of the injury can be successfully removed debris which could not 
possibly be attacked through the anterior nares. 


The following cases have been arranged into groups according to the site and extent of 
the injury : 

GROUP I represents the minor injury of loss of the upper quarter of the bridge of the nose. 

In GROUP II the upper half of the nasal bridge has been destroyed, producing a type 
of nose that one might call the "bird beak." 

GROUP III comprises cases where the bony ridge has been broken or destroyed : in these 
the tip still remains in fairly normal position, and the bridge is flattened, but there is no 
important loss of the lining membrane. 

GROUP IV deals with cases where the middle of the nose has been destroyed or crushed, 
and is accompanied by tilting of the tip (pug-nose type) and considerable loss of the lining 

Under GROUP V have been collected the Indian mutilation type, together with various 
cases showing loss partial or complete of the structures of the lower third of the nose, 
including the tip and ala 1 . 

GROUP VI. In this are cases of loss of the lower two-thirds of the nose, i.e. they are 
practically cases for complete rhinoplasty save that a small portion of the bony bridge 

GROUP VII. Total loss of the nose, and, in some cases, with loss of the bed on which 
the nose is built. 

Hums of the nose have been described in a separate chapter. 




This class of case is simple to treat in a number of ways, and a number 
of methods are available. 

The two cases illustrated have been treated by one method, the principles 
of which are the following : 

The skin covering is supplied by advancing flaps from the neighbourhood 
usually the glabellar region, the supporting structure is provided by the turn 
down of an osteopcriosteal flap from the glabellar region, while the skin lining 
is disregarded. 

The reason for the latter is that the apertures into the nose arc so small 
that they may be frequently obliterated by suture, or, if not amenable to this 
treatment, t heir continued existence at such a high point of the nasal cavity does 
not lead to infection and uleeration of the supporting structure. 



CASE 30 

In addition to the loss of the upper quarter of the nasal bridge, this man had lost his 
left eye. The covering was obtained by a straight advancement of the skin over the glabellar 
region flap A. 

After excision of scar at the bottom of the depression only a small opening into the 
nose remained. This was partly obliterated by suture. The small osteoperiosteal flap 

FIG. 391. The healed condition. 

FIG. 392. Result : note absence of artificial eye. 

was turned down and sutured to the back of the existing 

Details of this operation are appended. 

7.7.1G. Operation. A. "U "-shaped flap, with 
its base upwards, was dissected off the frontal bone, 
and a wedge of this bone turned down reverse side 
uppermost so that it met the existing bridge. An 
attempt was made to stitch it in this position with 
catgut. A portion, however, was broken in the pro- 
cess. The frontal skin-flap was brought down to meet 
the existing skin of the nose and the wound closed. 

13.8.16. Result. A small broken piece of the 
frontal graft was exfoliated ; otherwise, normal healing 
and the very satisfactory result from a cosmetic point 
of view. 

Fia. 3 93. Osteoperiosteal flap turned 
down from glabella. No skin. lining. 


CASE 87 

Shows an injury caused by a transverse bullet- wound. The eyes escaped damage. 
Tin- only difference in this case was that the flap from the glabellar region was secured by 

means of an oblique swinging advance- 
ment. Lines of the scar after operation 
are shown in the photograph, fig. 395. 
The osteoperiosteal flap was turned down 
in the same manner as in the previous 
case, and the details of the operation are 

1.1.17. Operation. 

flap from forehead to provide skin. 2. 
Hony support formed by turning down 
osteoperiosteal flap from the forehead. 

excised ; large oblique frontal flap turned 
up. Two vertical incisions through 
periosteum in line with nose. Small 
plate of bone chiselled o r f between these 
incisions, and bone, with periosteum, 
lifted and turned downwards over bridge 
and sutured into place. Skin-flaps ap- 
proximated over all. 

Fir.. :!!)4. Loss of upper quarter of bridge bullet wound. 

Fio. 39.1. Shows result. The oblique swinging 
frontal flap can be distinguished in its sutured 

Fio. 39C>. Kesult. Vartial side view. 



When this loss of the bridge is of a more extensive character, what' one has 
called the loss of the upper third or upper half of the nasal bridge the bird-beak 
class this method of osteoperiostcal support is not sufficiently firm, and has 
not been used. 

1 he ideal method for this repair consists of the implantation of the necessary 
cartilage in an adjacent skin-flap (the glabclla usually) as the first stage. Sub- 
sequently this cartilage and skin-flap are swung down together, and the necessary 
covering provided from the forehead. With loss in this situation it is not neces- 
sary to divide the repair into two stages, and the cartilage may be imbedded 
between the two flaps at the time of operation. lhe author has no case to 
illustrate this method. In one of the cases following, the support and lining 
were provided by a septal swing, followed by a later implantation of a cartilage 
rod. I his gave a sufficiently satisfactory result, lhe skin covering was pro- 
vided by advancement flap from the cheeks a bad method as a rule. In the 
other case no epithelial lining was provided, and the support was an osteo- 
periosteal graft from the tibia, while the skin covering was provided by an 
advancement of the skin between the eyebrows, lhe result was a partial 
failure, and the method is obsolete because no epithelial lining is provided. 



CASE 268 

In this case the loss of tissue comprised : 

1. The nasal bones, underlying portion of septum, frontal spine, and upper portions 
of nasal process of superior maxillae. 

2. The skin that should cover this part of the nose. 

3. The right eye. 

There was a small opening into the nose surrounded by scar tissue and granulations, 
which, when excised, left a bare area of about ^ in. square. 

4.6.16. First operation. Excision of scar, and submucous resection of a piece 
of the perpendicular plate of the ethmoid, which was swung forward to form a bridge, and 
sutured below to the septum of the lower nose with catgut. Two sliding lateral flaps from 
the cheek were cut, undermined, and sutured over this bridge with fine interrupted silk 
(vide fig. 399). 

Result, Slight breaking down near the angle of the right eye, which socket was not 
entirely clean. Primary healing of the rest, with excellent cosmetic results. As antici- 
pated, the bridge gradually sank, as the bridge of septal cartilage was not strong enough 
to support the contracting skin flaps. 

3.9.16. Second operation. Gas and oxygen anaesthesia by Capt. II. E. G. Boyle, 
who, on a visit, kindly gave a very satisfactory demonstration of this method. 

Small skin incision ; skin very carefully undermined from below upwards until the 
frontal bone was reached, when the depth was increased, and the periosteum incised and 
raised. A piece of rib cartilage of the necessary length was cut, fashioned, and inserted 
under the skin and periosteum, its lower end resting on the cartilage of the lower part of 
the septum. Catgut ligatures were inserted to hold it central, but, as the photos taken 
two months after show, the lower end slipped off the cartilage and produced a slight de- 

With the fitting of an artificial eye the result was very satisfactory. 

Kin. 397. Loss of upper half of bridge. 

Fio. 398. Result, two operations. Xote the slipping 
of the lower end of the cartilage rod off the septum. 
The fixation of a cartilage implant is most important. 



FIG. 399. Diagrams showing incisions, flaps, and suture of first operation. Note the wire retention suture 
from cheek to cheek, and the septal advancement as a support. 4.0.10. 

FlO. 400. Profile before. 

FIG. 401. Profile after plastic and cartilage implant. 



CASE 125 

This was a case of a similar condition. In its repair, both skin-flaps and the supporting 
structure were different from the previous case. 

In regard to the skin-flaps, the diagrams illustrate their use. The glabclla flap A was 
advanced to meet the nose (A 1 ), while two lateral flaps (B and C) were advanced to meet 
the sides of A. In order to close the nasal opening, a flap of periosteum only was turned 
down beneath A, see fig. 406. Supporting structure was furnished by a bridge of thin osteo- 

Fio. 402. Loss of upper half of nose. 

FIG. 403. The skin-flaps. A is advanced to A'.\ 

Flo. 404. Suture. 

Fia. 405. Early result. Xote relaxation button. 



periostcal graft from the tibia. It extended from the glabellar region to underneath flap A 1 , 
which was undermined. 

The immediate result of this procedure was very satisfactory, but, owing to the failure 
of the supporting structure to consolidate, the bridge fell in, and contraction and retraction 

In addition to the new bridge partly collapsing, the tip of the nose was slightly drawn 
up. Most of this failure was determined by the absence of epithelial lining. 

This case is published because it shows many interesting features to avoid. A better 
method for this particular case would have been as follows : 

First stage. Cartilage of necessary length to complete bridge imbedded in glabellar 

Second stage. This flap and cartilage turned down, skin surface inwards, and covered 
by a transposed frontal flap. 

Note. Big, straight advancement from the frontal region, as is evidenced in this case, 
does not give a satisfactory result, although the smaller ones on Cases 87 and 30 are quite 

Details of Case 125 are appended. 

13.2.17. Plastic Operation. The scar tissue surrounding the sinus into the nasal 
cavity was removed. Two incisions were made upwards on to the forehead forming a flap. 
Two more on either side were made running outwards on to the face, forming another flap 
on each side. 

A piece of periosteum was turned down from the frontal bone and the end placed over 

Another piece of periosteum, with a slight amount of bone attached, about 2 in. by 
1 in., was removed from front of right tibia and laid lengthwise, extending from forehead 
nearly to tip of nose. Skin-flaps approximated, as in fig. 404. 

Flo. 4!)(i. Shows indifferent final result of this method, due to the failure to provide an epithelial lining to the new 
portion of nose. Contraction and retraction have occurred. The diagram indicates the construction of the lining,--- 
periosteum only. 



Depression or destruction of the bridge of the nose without distortion of 
the tip or serious loss of the lining membrane. These cases are amenable to a 
restoration by implantation of a new cartilaginous bridge. 

1 he last of this group really belongs to Group IV, but, as it was treated on 
lines laid down as efficient for Group III, it is included here. Ihe indifferent 
result obtained in this case is due to the fact that one did not realise that there 
was serious loss of the epithelial lining. 

CASE 171 

The injury to this officer was due to a crash in an overturned motor-bus at the Front. 
In addition to the whole bridge of the nose being driven in, he suffered a depressed fracture 
of the frontal bone. He was admitted for plastic treatment of the resultant deformity. 
A double cartilage implantation was made, one to the bridge of the nose and a smaller 
piece in the depression over the frontal bone. This was an early case, and one did not 
appreciate the fact at that date that cartilage remains the same size as when implanted. 
Allowance was made for some absorption, which, however, did not occur. The profile 
restoration was good, except in the neighbourhood of the glabclla. and the general appearance 
was markedly improved. There was a slight displacement of the small plate of cartilage 
inserted in the depressed fracture of the frontal bone, and the nasal cartilage was a little 
too thick and too long. The cartilage for this restoration should be cut to the exact size 
necessary, and should be most efficiently anchored into position by catgut sutures or by 
tucking it under some periosteal flap. The slight deformity remaining could most efficiently 
and easily be cured by simple excision of the redundant portion of cartilage; but the pressure 
of war has prevented this officer from having this correction made. It is a mooted point 
whether this bridge could not have been raised by sub-mucous division of the nasal supports 
combined with a Carter type of bridge elevation. The frontal depression would have 
required separate correction. Details of operation are appended : 

31.3.17. ()]>i'r(itii>n. Semilunar flap, with convexity downwards, lifted from root 
of nose ; small periosteal and bone flap chiselled upwards, creating a notch to serve as 
support for graft. Skin over dorsum of nose down to tip separated from underlying tissues 
by undercutting, through original incision. 

Cartilage graft. .'i in. in length, taken from 7th costo-stcrnal junction in the right thorax, 
shaped, and inserted beneath skin and underlying tissues of nose as far as the tip and tucked 
in beneath the periosteal flap above. 

.Siiuill frontal scar separated from its deep adhesions by undercutting through original 
frontal sear, and a small piece of cartilage sutured in position. 




Fid. 407. Full face. FIG. 408. Profile. 



FIG. 409. Full face. 

FIG. 410. Profile. 

Note : the prominence in the glabellar region can bo 
easily dealt with by excision of redundant cartilage. 

_".' t 


C.'.SK 102 

This case shows loss of all the lower portion of the nasal supports, and the interest 
of the ease rests in the successful application of dental nasal splints as a preliminary measure. 
Had this splint been available a few hours after the receipt of the injury, it is possible that 
the restoration by this means might have been even more perfect. It is, however, to be 
recognised that there is loss of the external skin and epithelial lining and of the septal sup- 
ports. Therefore, no mechanical restoration could have been perfect. A very nice-looking 
and satisfactory nose was obtained, as a result of cartilaginous implantation, but it is not 
a restoration to the normal, because no provision was made for the accompanying loss of 
lining membrane. It is especially to be observed that, despite the satisfactory restoration, 
the alie are drawn up on each side and the tip is still somewhat depressed. 

In regard to this cartilaginous implantation, it is the first time, as far as the author is 
aware, that a piece of cartilage was used down the columella to prop up the bridge cartilage 
and the tip. This method of supporting the tip has become almost a standard practice in 
the later development of our rhinoplastics. Operation, etc., notes given below : 

Restoration of the nose by splint and cartilage graft. . . . Wounded on 20.12.16. 
The condition on admission, nine days later, to the Cambridge Hospital, Aldershot, is shown 

FIGS. 411 and 412. On admission. 

in figs. 411-412; the anterior part of the septum, with portions of both alse. having been 
shot away, a considerable flattening of the nose resulted. 

15.1.17. /'/;*/ operation 1\\c flattened portions having been freed of all their 

adhesions, the apparatus shown in fig. 413 (drawn by Professor H. Tonks), (made by Captain 

King and staff) was inserted. '\ his was continuously worn by the patient for seven 

weeks and produced a very considerable improvement, as sliown in fig. 414. Figs. H 5-416 

later and permanent result of the insertion of a graft 3 in. in length, taken from 

the eighth rib. to raise and support the lower part of the nose. The cartilage was inserted 

in two Portions through the columella; the longer portion was pushed in beneath the skin 

rm the bridge, while a shorter piece was imbedded down the columella towards the 

i so as to support the tip of the nose. Plastic re-suture of the ala; to give symmetrical 

iranee was carried out at the same operation. To Captain Kclsey Fry, MX'., belongs 

t nl giving the nasal splint the prolonged trial, which ended successfully. 



. 413. Retention apparatus for the ncse. It is 
fixed to the upper teeth by a metal cap splint. 

FIG. 414. Result obtained by operation and the 
wearing of the apparatus for seven weeks. 

FIGS. 4 15 and 410. Result of plastic opDrations on aloe, and cartilage support to the bridge. Cartilage was 
inserted in two portions, one along the bridge and one down the co'.uinella. Date of operation, 9.3.11". 




CASE 36 

This is an example of a definite group of nasal injuries. Those cases coming to one's 
attention have been due to high-velocity bullets at short range, traversing the face ap- 
proximately from one malar region to the other. Encountering hard bone on the way, 
its force is "transmitted to the upper jaw, detaching it from its superior attachment. The 
whole support of the nose is also destroyed, and replacement of what remains of the sup- 
porting structures is very difficult, unless a case is specially treated for this within a few 

davs of injury. 

The complete detachment of the superior maxilla is well shown in the photograph, as 
is the condition of this officer on arrival. The whole face is lengthened, and, while his lower 
jaw is fully open, his upper teeth are in contact with the lower. Ihere is some evidence 
of recession of the upper lip owing to loss and displacement of the underlying bone. In 
this particular instance an attempt was made to replace the nasal bones by intra-nasal 
supports, but completely failed. 1 he treatment of the fracture of the upper jaw was under- 
taken by Captain F. E. Sprawson, R.A.M.C., with Kingsley type splints, and the excellent 
result is well seen in the shortening of the face (fig. 419). Union has occurred in the upper jaw. 
Details. The sniper's bullet entered by the right malar and came out, after fracturing 

the maxillae, through the left cheek at the side of the 
nose, and the whole of the nose was left very flat and 
broad. On his admission, fourteen days after injury, 
an immediate effort was made at replacement by 
intra-nasal splints, but without appreciable success, 
due to the actual loss of bone. 

Four months later a plastic operation was per- 
formed to raise the line of the bridge by means of 
perforated shaped celluloid. The diagram of this 
sufficiently illustrates the manoeuvre. It was 
moderately successful in appearance, but there con- 
tinued to be some slight discharge combined with 
protrusion of the celluloid at the tip of the nose, and 
it had to be removed after two months. The cellu- 
loid plate was J in. thick. After four months, during 
which the small scar at the tip of the nose, produced 
by the celluloid, was excised under local anesthesia, 
the patient was again operated. A thick piece of 
rib cartilage, 3 in. in length, was taken from the right 
thorax (8th) ; this was grooved on its under surface 
so as to obtain greater fixity of position. From a 
semi-lunar incision, with its convexity downwards, 
at the root of the nose, the skin over the dorsum of 
the nose was freely under-cut. The graft was inserted, 
and its upper end wedged under a small periosteal 

flap of the frontal bone. In order to give more prominence at the middle of the bridge, a 
second smaller piece of cartilage was superimposed, while a third quite small piece, through 
a separate incision, was used to reinforce the left ala. Slight suppuration followed this 
operation, and lateral incisions were made about half-way down the nose. This infective 
discharge continued for the best part of three months, i.e. until 26.6.17. Four months 
later the condition was fairly satisfactory ; the main graft had not become infected, but had 
somewhat moved its position, and, covered by mucous membrane, was plainly palpable at 
each nasal orifice. There is deficiency of prominence of the tip, while the left ala has not 
been readjusted since the wound. Scars were also present from the previous incisions. 

To correct these deformities, the following operation was carried out. A sub-mucous 
resection of the cartilage graft through the right narcs was effective in increasing the size 
of the nasal passage and in providing a piece of cartilage. This incision into the mucous 

Fio. 417. Diagram to represent the im- 
plantation of a celluloid support to bridge 
and columella. Result : failure. 



Fio. 418. Condition on admission. Double fracture of maxillae with downward displacement. 

membrane was carefully sewn up with horsehair. The piece of cartilage obtained was 
roughly an inch long. It was shaped and inserted, through a small lateral incision in the 
columella, under the tip of the nose to give this more prominence. Small scars were removed, 
and the left ala was lengthened and brought more central. All wounds healed by first 
intention, and the result was satisfactory. This is probably the first time that a sub-mucous 
resection of imbedded cartilage has been carried out and the cartilage reimbedded in 
another portion of the nose. 

28.11.17. Discharged to duty. Result very satisfactory. 

1.4.18. Returned for reconsideration. No further plastic is at present advised. 
Still requires a small portion on the tip of the nose. Although the nose in itself is fairly 
good it is set too far back on the face, owing to the fracture with loss of the superior maxilla. 

FIG. 419. Result of replacement of maxilla; and cartilage implant to nose, etc. The scars on tip and 
lateral aspects of nose are due to suppurative troubles. 




CASE 252 

This is another example of complete upper jaw detachment, with destruction of the 
nasal supports. The injury was due to a bullet at short range. 1 he entry and exit wounds 
are visible in the fig. 422. The terrible deformity is best realised by examination of fig. 4'20. 
which portrays his condition before being wounded. The whole of the upper part of the 
face seemed to move on a line running from the mid-part of the glabellar region through 
the orbit above the bony floor, and through the external angular process to the temporo- 
mandibular joint. 

The treatment given this case was, first of all, an attempt to manipulate the nose and 
upper jaw into position, and the fitting of a Kingsley splint. Two months later it was 
found that no union had occurred, and a stronger type Kingsley was applied. 

Serious damage had been done to this patient's vision, which became worse when this 
stronger splint had been in position for a few days. T he splint was removed and the eyes 
examined by Captain Williams, and Mr. Holmes Spicer, of London. An exploratory 

operation was advised. Captain A. Ryland, K.A.M.C.. 
investigated the various sinuses, especially the sphenoi- 
dal. Isio pus was encountered, but after a severe epis- 
taxis, the vision gradually improved to a certain extent. 
To decrease the deformity of the bridge, a combined 
bone and cartilage graft from the rib was inserted from 
above six months later. The diagrams attached show 
the shape of the graft after it had been fashioned. The 
bony portion was split and fitted over the freshened 
nasal bones like a penthouse, while the attached car- 
tilaginous rod extended down to the tip of the nose. 
A very marked improvement in profile occurred, but a 
twist developed in the car- 
tilage, which marred the 
effect. This operation is 
described because it is an 
important eilort to replace 
the nasal bridge by its two 
elements, bone and car- 
tilage. Bony union oc- 
curred between the rib and 
nasal bones. A piece of 
cartilage under the left eye 
slipped out of position. No further treatment has been undertaken for this patient. 

After consideration of later cases, there is no doubt that this case should have been 
treated on the lines of Case 155, which follows, and is a definite failure because no provision 
w.-is made for the large amount of epithelial lining which had been shot away, and which 
had necessarily to be supplied before the nose could be restored to a normal position. 

These three cases, 36, 155, and 252, are all similar, but of increasing severity of loss. 
On the one hand, Case 36 was successfully treated by cartilage implantation alone, while 
( ;isr 155 had a considerable new amount of skin-lining as well as support provided. , Case 252 
was treated on the lines of 36, but should have been treated as was Case 155. 

Fia. 420. Before wound. 

FIG. 42 1. Bone-cartilage trans- 
plant from rib. The bony part 
is split and is shown black in the 



FIG. 422. On admission. Note downward 
displacement of maxillae. 

FIG. 423. After replacement of maxillae by 
dental splint. 


FIG. 424. After bone-cartilage graft. See reading matter re defects in designjand technique which 

produced this inferior result. 



Having discussed the transition Case 252, it will have been seen that the 
author tried to treat Case 155 at first on the lines of supplying support only. 
Fortunately this was a gross failure. 

The characters of this group are that there is complete loss of the bony 
and cartilaginous support, together with serious loss of the lining membrane. 
The tip becomes drawn up and back until the nostrils and columella are so 
distorted that the anterior nares, instead of looking downwards, look directly 
forwards, or even upwards. " Pug-nose " is the name given to this type of 
deformity, and it gives the unfortunate possessors a most repulsive appearance. 
Treatment on the lines of distending the skin of the bridge by cartilaginous 
or other support is useless because, as has been explained before, it was all- 
important to provide the necessary skin lining in addition. It occurred to the 
author that the supporting cartilage might be previously imbedded in the flap of 
skin to be turned down. A double principle .is involved in this procedure, viz. (1) 
provision of the important skin lining ; and (2) the imbedding of the cartilage 
in this flap rather than in the external covering flap. Advantages accrue in 
that the necessary length of cartilage is easily gauged, and when imbedded 
remains in its position ready for inversion or swinging down. Experience has 
shown that a cartilage imbedded in the forehead often moves its position or is 
bent out of shape. A further advantage lies in the fact that in the process 
of hingeing of the flap of skin and cartilage there is a distinct tendency for the 
cartilage to spring back. This naturally has the effect of supporting and raising 
the extremity of the nose, and the amount of spring can be nicely judged while 
the undercutting of this skin-cartilage flap is accomplished. It is a definite 
scientific procedure, capable of being pre-judged. The name given to this 
flap is the " Vallancey swing," named after the case for which this flap was 
first designed and used. As explained in the chapter on Principles, the 
author lays claim to this " swing " as a definite new principle on which a number 
of plastic procedures are based. To comply with the tenets of this principle 
the supports or cartilage must be previously imbedded in the flap that is to be 
inturned. The method is applicable to many nose operations where support 
and lining arc required, such as are to be found in the following three Groups of 
cases, IV, V, and VI; also for plastics of the ala3, of the eyelids, for ear 
restorations, and even for the chin. It is further applicable to tracheal repair 
and other plastic procedures. 

Another new principle of a minor importance was evolved in this case, 
and that is the creation of a cartilage store in the subcutaneous tissues. 


Sufficient cartilage for the whole restoration, with a spare piece for accidents, 
is taken at the one rib-operation, and the spare piece is inserted under the skin 
of the upper abdomen or thorax for future use. It is then available at any 
time, and can be easily reached under local anaesthetic. The rib operation is 
a distinctly painful one, and avoidance of a second is a great advantage to the 
patient. Moreover, if the spare cartilage is not required it can be transferred 
to another patient, saving him a rib operation. 


The typical pug-nose is shown in the following case, 155. Ihe treatment 
of this condition has been standardised as a result of operative procedures in 
this case. 

The " Vallancey swing " consists of a prior imbedding of a piece of cartilage 
of the necessary length in the middle line of skin remaining over the glabella 
and upper nasal region. The tip containing the pug-nose alas is definitely 
separated from the upper half, and the gap into the nose between the two kept 
open until the second stage of the operation. 

The cartilage, having been successfully imbedded, is raised with the flap 
of skin over it, and swung directly downwards, its lower end acting as the hinge 
and blood supply. 

Ihe skin over the cartilage thus comes to line the nasal cavity where that 
lining is missing, and the end of the cartilage is inserted under the structures 
of the tip of the nose which has been brought down to a normal position by 
cutting its attachment deeply. 

The rod of cartilage thus inserted into the tissues of the tip effectively 
prevents the tip from being pulled backwards and upwards. To complete the 
operation, a skin covering is usually provided by a frontal flap. 

This radical method is absolutely effective and produces uniformly good 
results. Great care must be taken that the inverted skin-cartilage flap has 
sufficient blood supply. This can usually be secured at the first stage of the 
operation, by attaching what is going to be the pedicle of the inverted flap to 
the mucosa of the nasal cavity. It occurs sometimes that the blood supply to 
this flap is not sufficient to permit complete incision around its lateral attach- 
ment ; it is then necessary to leave a pedicle of skin from one or other side of 
the nose to be divided later. 

When the " pug-nose " retraction is not marked, and is mainly due to scar 
tissue, it is not always necessary to insert the cartilage ; but the principle re- 
mains the same. See Cases 558 and 598, 


CASE 155 

Wounded 19. 9. 10. 

He was admitted under me on 12.3.17. A mucoccele of the left lachrymal sac had 
been operated by the ophthalmic specialist at the Cambridge Hospital, Aldershot, Capt. 
Williams, R.A.M.C. 

FIGS. 425 and 426. Condition on admission. The Pug-nose deformity. 

At this time the author was giving various implanted bodies a thorough trial, and de- 
cided, in consultation with one of his colleagues, to insert a perforated sheet-silver bridge of 

Flo. 427. Diagram of a paraffin-covered silver support introduced to raise the bridge. Failure. 

the form shown in the diagram. This bridge was carefully covered with sterilised paraffin wax 
ting point, and, after thorough undercutting of the skin, was imbedded in the 



FIGS. 428 and 429. Show the first stage of the author's principle of nasal reconstruction. 

tissues. The immediate cosmetic result was not at all pleasing, and, in addition, the chronic 
irritation of the tissues followed by suppuration necessitated its removal. 

In the following November, some six months later, the first stage of restoration was 
carried out. The operation notes are as follows : 

Stage I. Establishment of airway cartilage imbedded. The method selected was 

FIG. 430. Illustrates the author's principle of carrying 
spare cartilage subcutaneously for later stages. This 
saves any further rib operation. 



FIG. 431. A is the skin-cartilage flap which is swung down to form an epithelial lining to nose, 

a support to the bridge, and a prop to prevent the retraction of the tip of the nose. 

FIGS. 432 and 433. B is the frontal flap to form the external covering. The lining is formed by the skin of A 
now inverted, and the support by the cartilage, which now comes to lie between the two skin-layers. 

to imbed a short piece of cartilage in the stump of the nose, and, later, to turn this down 
skin surface inwards. 

This piece of cartilage was taken from the right costal region and imbedded through 
a small incision at the root of the nose. In addition, an aperture was made in the nose 
from just above the tip and the edges of the skin tucked in towards the nasal passage. Ad- 
ditional cartilage was removed and imbedded in the abdominal wall beneath the skin for 
the following reasons : 

A. As an extra piece for the nose. 

B. As a cartilage prosthesis for the eye. 

C. Spare piece. 

All wounds healed aseptically. 

Stage //.Flap A in the diagram, fig. 431, containing cartilage, was swung down, leaving 
the lower portion attached for deep blood supply. The tiny pedicle of skin was also left 
on the right lateral aspect for further nourishment. The tip of the nose was now freely 
undercut until it could assume a normal position and the extremity of flap A was sutured 
to the back of the columella, the cartilage being fitted into the tissues of the tip. 



Necessary sutures were inserted around the margin of 
flap A, which completely closed the nasal cavity from 
the operative area, except for its tiny pedicle above 
mentioned. A model of the raw area now exposed was 
made in tin-foil, and a flap of the exact size was cut 
from the left temporal region and sutured in position. A 
portion of the tip was swung down to give a little more 
prominence, and a corresponding addition to the frontal 
flap made to cover this extra raw area. A skin-graft 
was applied to the extremity of the raw area in the 

Stage III. Return of pedicle to forehead, and 
correction of eyebrow levels. The fistula resulting from 
the little pedicle to flap A. stage 2, was excised. Im- 
plantation of cartilage to upper part of bridge. 

The satisfactory result produced in this case is per- 
manent as far as can be judged. There is no change 
except for the better (one year after opeatiron). 

FIG. 434. Sectional view 
of flaps A and B, with the 
cartilage lying in between. 

Fio. 435. Profile view of result. Compare with 
original profile. 

FIG. 436. Front view. Artificial eye inserted. 



CASE 558. Type : loss of the middle third of the bridge of the nose and of the semi- 
pug variety. 

The interesting points about this rhinoplasty are (1) the absence of cartilage support ; 
(2) the method of re-making the left ala to produce symmetry ; and (3) the question whether 
it would not have been better to have made the frontal flap larger, so as to have covered all 
the external surface. It seems to the author that it should have been brought down to cover 
the new portion of the left ala, as at this spot there was some redness of the skin probably 
due to the presence of mucous membrane otherwise, compare it with Case 598 (p. 240). 

Point 4. When the pedicle was returned to the forehead, a plastic flap of the scalp 
was cut, and advanced to fill in the gap. As this man has weak fair hair, the advancement 
of the hair-line is of no disability. A further point of interest should be noted, in that the 
usual first stage of such an operation was omitted, \iz. the establishment of the airway 
and replacement of the parts in their normal positions. The usual first stage also includes 
sewing the base of the inturned flap to the mucous membrane to ensure its blood supply, 
and in this case, in order to secure the blood supply, a small skin pedicle was left on the 
right side. Subsequent to the return of the pedicle a large collection of epithelial debris 
had to be evacuated from the right side of the nose. 

A bone-graft from the tibia had been inserted into the bridge of the nose prior to the 
patient's coming into the author's hands. Various other plastics had apparently been done 
before his admission. There was a loss of the inner half of the left ala, and a spicule of the 
bone-graft was discovered on top of the nasal bones. 

The method of operation consisted of excision of scar tissue and freeing the tip and left 
ala, until their normal position was assumed. The skin over the upper part of the bridge 
was then reflected downward on its deep base. As the blood supply was insufficient, a 
small skin pedicle was left on the right side. When this flap was inverted, it was sewn 
to the back of the tip and alse. In order to complete the contour of the left ala a portion 
of the tip. marked B l , was swung to the left and sutured to the remains of the left ala (.B 1 ). 
To cover the raw area thus produced, a forehead flap of exact size was taken from the left 
frontal region and sutured into position. Union was satisfactory, and, despite the fact 
that no cartilage was in the inturned flap, there was no tendency for the tip to retract. 
The pedicle was returned two months later, and the gap in the forehead was repaired by a 

Tip oF nose brought down and 
rwintamed by inverted Hap C. 
In C was a little ostepfibrtus tissue 
the result of a previous tcbal graft 

^< ''NV 
</ V-."' r)/ 

437.-B is the frontal flap to cover the defect. Fl o. 438.-The gapjn the forehead is closed by the return 

of the pedicle and by a " V Y " advancement of the scalp. 



FIGS. 439 and 440. Pug-nose, combined with ala deficiency. 

FIGS. 441 and 442. Soon after the reconstruction. (The lymphatic oedema has not yet subsided.) 

k V Y " advancement of the scalp. Some later trouble occurred, due to the tiny pedicle 
of the inturned flap of the first operation ; an inclusion epithelial cyst developed on the 
side of the nose. It was freely excised, and no further trouble has arisen. The final result 
is shown in the photographs. The eyelid plastics are not yet complete. 



(ASK 495. The disability and the necessary radical nature of the repair were originally 
much under-estimated in this case. 

It was first thought that by freeing the nose on its right aspect one should be able to 
centralise it and then raise it by cartilage graft. An epithelial graft was therefore made 
to free the adhesion on the right, and an apparatus to align the nose was worn by the patient 
for some time. It certainly straightened the nose to a considerable degree, but it was realised 

FIG. 443. Pug-nose, with much lateral loss 
and consequent deviation to the right. 

FIG. 444. Profile of healed condition. 

then how inadequate the procedure was ; moreover, a severe blockage of the nasal airway 

Therefore this first idea was abandoned, and the case was treated on the usual lines of the 
other skin cartilage flaps. A flap of the exact size was cut to fit the raw area of the nose, 
and, although this was sufficient for the nose, no allowance was made for loss of skin of the 
cheek ; consequently, there is still a slight dragging to the right, although the whole result 
is a very satisfactory one. The least support with an extra piece of cartilage would have 
rectified this want of alignment, but the patient was so satisfied that he did not wish to have 
anything further done. 

The tip has been brought down a little too low, but could have been further raised by 
the implantation of a columellar rod of cartilage. This procedure definitely established 
a good airway through the nasal passages. 

The pedicle was not returned to the forehead as the scar-line there was sufficiently 
satisfactory ; hence an excision and rearrangement in the glabellar region such as that in- 
dicated. The operation details are : 

12.4.18. Operation. Epithelial outlay inserted under right aspect of nose and right 
ala to allow this to swing forward into position. The bridge to be dealt with later. The 
edges of the skin graft, which was cut very thick, were included in the sutures which kept 
the stent in position. 

2 2. 7. 18. Epithelial outlay successful deviated nose returned to normal alignment. 

22.7.18. Operation. Preliminary nasal plastic. Cartilage from eighth right rib 
shaped and inserted on the bridge of the nose through incisions between eyebrows. Tip 
of nose then released from the remainder of the nose : skin and mucous membrane sewn 
together. Nasal passages freely opened, and airway established. The remaining unused 
cartilage was imbedded under the skin covering the chest. 

Result. Satisfactory healing. Airway established. 



FIGS. 445 and 440. First stage, showing the restoration of the tip to normal FIG. 447. Diagram of second stage operation, 

position and tho imbedding of cartilage in the glabellar region. 

FIG. 448. Diagram of method of treatment 
of the pedicle and advancement of scalp. No 
skin graft. 

FIG. 449. The result. 

22.8.18. Operation. The glabella flap A was swung down with its contained cartilage, 
the end of which was inserted into the tissues of the tip to hold the tip down and straight. 
The old skin-graft on right side was excised. The edges of flap A sewn to mucous membrane 
to complete closure of nose. A flap of the exact size was cut to pattern and the forehead 
sewn up. Result : very satisfactory. 

14.11.18. Pedicle partly returned and partly excised. 



CASE 508 

In addition to a major loss of the upper lip and the adjacent portion of the cheek, this 
patient suffered destruction of all the lower part of the nose save the columella and left ala. 
Some beautifully drawn diagrams by Lieut. D. E. Lindsay, attached A.A.M.C., graphically 
describe the methods of repair. 

The columella had to be freed and resutured in its, back surface, so as to have no ten- 


FIGS. 450 and 451. Loss of the lower part of the bridge and right ala. Lip deformity. 

dency to retract upwards, and a complete new right ala had to be made in addition to the 
top of the nose. For some reason which is not recalled no rod of cartilage was implanted 
prior to the restoration, and the flap of skin from the upper remaining portion of the bridge 
was swung down and sutured to the back of the tip and left ala. The lining of the right ala 
was made by dissecting out a lateral flap from the large deep depression over the right 
antrum. This was turned skin inwards and sutured along the lower border of the first 
flap. A right frontal flap of exact size and shape was brought down over this raw area. 
Xo attempt was made to repair the cheek and lip deformity. It is proposed to insert some 
cartilage between the two flaps to give the lower part of the nose a more definite shape. 
A very excellent line of union has been obtained between the old and new parts of the nose, 
so that in certain areas the line is indistinguishable. An excellent forehead scar was also 
produced, and instead of replacing the pedicle it was excised and the eyebrows rearranged. 
The right eyebrow is still slightly higher than the left ; but this is more than counter-balanced 
by this small frontal scar. The upper lip and cheek repair is a specially shaped flap, which 
was considered suitable for this case. Operation details are given below : 

22.6.18. Operation. An incision made over the skin of the upper portion of the 
nose, as marked on diagram, which enabled flap A to be reflected skin inwards. At the 
same time, this incision freed the remains of the columella and left ala so that they could 
be brought into normal position. 

The extremity of flap A was sewn behind the columella. Flap B, which was a natural 



flap lying inside scar lines, was reflected inwards to line the right ala, and sutured to the 
under surface of the tip and along its upper border to flap A. The reflection of flap B was 
carried right up to the nasal aperture, so that there was a good curl for the new ala. A 
suitable flap, cut to the exact size of the nose, was turned down from the right frontal region. 

Fio. 453. Lettering has been omitted on diagrams 
Flap A is the upper, and flap B the lower, of the two 
flaps. Both are shown after their inversion and suture 
to the back of columella. 

Fid. 452. Diagram of healed condition. 

No attempt was made to extend this flap to take any part in the repair of the cheek. In 
regard to the cheek, the deeply depressed scar was excised, and, as a preliminary, a fat- 
flap was turned in underneath it and the tissue of the cheek advanced to meet the upper 
lip. No attempt made at this operation to correct ectropion of upper lip. Progress very 

FIG. 454. Raw areas after excision of scar 
and inturning flaps to line nose. 

Fio. 455. Shape of the frontal flap and its suture as 
the external covering of the new portions of nose. 


_' H' 


15.8.18. Operation. Treatment of nose pedicle. 

(1) Partial excision of redundant skin. No replacement, as the eyebrow was only 
slightly raised and the forehead scar was very good. 

(2) Excision of scar tissue above right corner of mouth. The remaining portions of 


FIG. 456. The lip incision. 

Fio. 457. The lip suture. 

the upper lip hereabouts were freed as two small flaps, and sewn together in correct position 
to complete vermilion border. To fill the large gap caused by this rectification and the 
excision of the scar, a new flap was designed (original) model is attached and sewn into 
position with catgut and horsehair. It fitted very snugly into position, owing (1) to being 
cut on the curve ; (2) the extra excision of some indifferent skin to allow the pedicle to 
twist easily. Secondary closure difficult but satisfactory. Retention sutures used. 

Fio. 4. Hap to reconstruct upper lip and cheek FIG. 459.-Suture. This diagram also shows method 
nasal reconstruction. of deaUng with the nose pedicle by excision as compared 

with replacement. 



FIG. 460. Frontal flap in position. 

FIG. 461. Pedicle returned and lip repaired. 

FIG. 4C2. Same full face. Note the slight 
elevation of the right eyebrow. 




After examination of the first record, one is inclined to regard this case as a minor 
injury. In fact, it was not thought that it would be necessary to do more than an excision of 
scar combined with a small cosmetic implantation of cartilage. This was an error of diag- 
nosis, in that one had not appreciated the amount of loss that had already occurred, and what 
was going to occur, in the middle structures of the nose. The left antrum was involved and 
most of the bony supports on the left side underwent necrosis. Unfortunately, a photograph 
was not taken of the stage immediately prior to operation, but an excellent plaster cast. 
by Lieutenant J. W. Edwards, Sculptor to the Department, has preserved a record of this 
stage. Comparing this with the photo, it will be seen what a large deformity had super- 
vened. A very small " Vallancey swing" was used, and the frontal flap was carried on a 
long tube-pedicle, containing a branch of the superficial temporal artery. A most excellent 
repair was effected, with invisible scars. A part of the tube was subsequently imbedded 
in the cheek beneath the left eye to fill up an existing hollow, and the rest of the pedicle 
was returned to the scalp. It should be observed with these long pedicles, having a large 
arterial supply, that a sufficient venous return is provided ; otherwise thrombosis is liable 
to occur at the extremity of the flap. No fear of this occurred in this instance, as the pedicle 
was cut sufficiently wide. The great advantage of this method of bringing down the neces- 
sary skin is that it leaves the lower part of the forehead untouched by scars, and the scar 
remaining is one running parallel to the natural lines. The operation notes of this case 
follow : 

16.7.18. Operation. Cartilage from rib removed and inserted over bony bridge of 
nose, and spare cartilage imbedded in abdominal wall subcutaneously. Scar tissue now 
freely excised. Lower part of nose freed and by careful suture of skin and mucous membrane 
retained in its normal position. Similarly, skin was sewn to mucous membrane in upper 
margin of the central nasal aperture and airway established. Result satisfactory. 

Fid. 403. Cast on which the flaps were 
designed. The lining and support were 
made by inverted flaps, that over the 
bridge ,,, laming a rod of cartilage 
The supoHic-ial temporal flap is outlined 


FIGS. 464 and 465. Condition when suppuration has ceased and skin edges 
have been united to mucous membrane around the aperture. 

FIG. 466. Cast of the suture. Note Fio. 467. Diagram of the reconstruction. Fio. 468. Shows the tube-pedicle lying 

the tubing of the temporal flap. on the cheek. 

FIG. 469. Result after return of pedicle. Fia. 470. Side view. Note that part of the pedicle 

has been imbedded in the cheek to raise the eye. (This 
has been smoothed out by subsequent operation, in- 
cluding a small cartilage transplant from the left ear,) 

14,10.18. Operation. I. Small flap with its contained cartilage over bridge of nose 
cut, undercut, and swung down, skin surface inwards, and sutured to back of tip, extremity 
of cartilage extending into the tip. The upper edge of the tip had to be freely excised in 
order to arrive at healthy skin. 

2. Instead of carrying this flap on the usual pedicle it was carried by a pedicle along 
the left temporal artery. When sutured into position the pedicle lay across the cheek 
beneath the left eye (see photograph). Pedicle tubed and flap sutured into position. Fore- 
head closed by approximation. The upper part of the bridge from which the small flap 
had been taken was covered in by approximation over the bridge. Result very satisfactory. 

Stage ///.Part pedicle returned to scalp. Part imbedded in cheek local anaesthesia. 




The seven cases under this group vary from a very minor injury to the tip 
and ala to the major loss of the lower third of the nose. Intermediate between 
these two extremes lies the type known as the Indian Mutilation. The more 
severe cases border on the next, or Group VI, in which is described loss of the 
lower two-thirds. 

CASE 730 

This Case is chosen for illustration for several reasons. In the first place, it is an ex- 
ceedingly minor injury, the design for the repair of which gave the author considerable 
concern. The rest of the face is absolutely untouched, and one hesitated to make a scar 
anywhere. How was. one to provide the skin covering and lining ? After considering the 
various possibilities, such as the tubed temporal region flap, and a flap from his arm or neck, 
it was decided to attempt a whole-thickness free-graft. On the forehead, these whole-thick- 
ness grafts are almost uniformly successful, but in that site the immobility of the surrounding 
parts and the excellent blood supply probably determine their success, whereas newly 
swung inturned flaps were not considered a very hopeful bed. As will be seen, the graft 

Fio. 471. Shows inversion of small skin flaps in 
neighbourhood of defect to complete lining and support 
for graft. 

Fio. 472. The graft sewn into position. 

was successful, and a symmetrical tip was produced. There is, however, no prominence 
to it as no supporting tissue could be utilised. It is possible, however, that after an interval, 
say of a year, cartilage of satisfactory size could be imbedded. Following are details of 
the repair : 



FIGS. 473 and 474. Show the effect of thu injury. There is loss of part of the tip and right ala. 

FIGS. 475*and 476. Result of Wolfe graft. 

17.12.18. Operation. Attempt to make a whole-thickness skin-graft instead of flap. 
To form lining of right ala, a flap from the left was swung across and stitched to the skin 
of the vestibule on right side. Scar tissue excised and raw area made, symmetrical. A 
whole-thickness graft cut from the arm was stitched into place. Graft took in its entirety. 



CASE 258 

An even smaller loss of the tip than the first illustration in this group. This loss was 
treated by simple swinging advancements of a whole thickness variety that is to say, 
the flap made consisted of skin, cartilage, and mucosa. 

This gave a fairly satisfactory result, but is obviously a compromise, and hardly a 
reconstruction. An attempt to swing the right ala further forwards and down resulted 
in suppuration, which marred the effect. The case was an early one. 

Fio. 477. Incisions for advancing flaps. 

Details of operation are appended. 
Partn; 6 ;^ 01 *" 1 * 1011 f u F reformation of tiP f nose. A thick flap containing skin 

"ted t Tn COU f S T m n anC T 5 , CUt accordin g to dia gram, and brought down and 
to remains of columella and ales to form new tip 

spoilt Vhl' res'ul?^ 1 ' "'" 11116 " ght ^ W&$ lndsed &nd br Ught forward ' Suppuration 
right*'? ; * ^ * ^ ^^ ^ ^^ f 



Fid. 478. Partial loss of the tip. 

Fio. 479. Result of treatment. 



CASE 381 

An atypical deformity of the tip and left ala. The interest of this case centres in the 
use of a caterpillar flap in which a good section of tissue is made to advance in two stages 
on its own pedicles. First of all, the lower end is used as a base, and the upper end is ad- 
vanced towards the lower. A hump is thereby produced in the middle of the flap. W hen 
the upper part, thus moved, has an attachment and a blood supply, the lower part is raised 
and the hump straightened out. 

Never having executed this manoeuvre before, one was fearful of difficulties of blood 
supply, especially in the second stage. However, the first stage proved to be the more 
dangerous, while the second stage gave me no cause for alarm. 

27.11.17. Operation. A blob of nasal tissue was lying in the middle, which would 
make a useful tip if it could be shifted down into position. An attempt to do this was 
made in the following manner : 

The skin from the dorsum of the nose was incised so as to allow it to shift down cater- 
pillar fashion as a first stage. It is hoped that in the second stage, when the caterpillar is 
straightened out, the fleshy lump above referred to can be raised and brought into position 
for the new tip. The blood supply of this flap was not at all satisfactory, and it had to be 
loosely sewn together afterwards. It is doubtful whether the blood supply to the flap 
from the new position will be sufficient when the lower mass is detached. The diagrams 
represent the first stage of the caterpillar movement. 

26.2.18. Operation. The blob above referred to was detached from below and the 
back of the caterpillar straightened out. Great care was exercised in separating the two 
halves of the middle hump. The blood supply of the flap appeared quite satisfactory, and 
the flap made a very satisfactory tip. It was not quite broad enough to fill up the gap on 
left side, and, as it was not deemed advisable to put it on tension, this gap was filled by a 
whole thickness of skin-graft from the lobule of the right ear. Adjustment of the remains 
of the columella and new tip were made. 

Progress. The free graft did not take ; otherwise satisfactory. 

2.7.18. Operation. Redundant portion of columella excised, and portion of the new 
tip swung to left to complete new ala. Result satisfactory. 

24.7.18. Excision of small scar left side of nose under 2 per cent, novocaine. 

3.9.18. Discharged to duty. 

? further treatment any advantage. 



FIG 480. Incision for first stage. 

FIG. 481. Suture of the first and second 
Below, the caterpillar principle. 



FIGS. 482 and 483. Condition on admission. 

FIG. 484. First stage of caterpillar movement. 

FIGS. 485 and 486. Besult of this advancement. Note the defect of the left ala. 



CASE 70 

The following case is shown as an example of a compromise. The large columella 
is detached from below and converted into the left ala, which is missing. This manoeuvre 
gives a fairly satisfactory appearance by very easy means. The absence of the columella 
is a distinct disadvantage. In this particular patient the rest of the wound was so large 
and important that an operation which would quickly obtain a result was indicated. The 
case is illustrated because this particular manner of making an ala may be found useful 
in other cases. The details of the case and the diagrams of the cheek operations are included 

Fio. 487. Detaching columella. 

FIG. 488. To make ala. 

28 . 11 . 16 . Operation. Removal of sequestrum. 

Condition. Large loss of cheek and left ala of nose. 

METHOD OF TREATMENT. 1. Lateral sliding and ascending cheek flaps. Successful. 
2. Local fat-flaps under depressed scar. Satisfactory. 3. Formation of left ala, by 
utilising columella. A satisfactory makeshift. 

PLASTIC OPERATION. 27.9.16. Plastic operation on face. 

PLASTIC OPERATION. 27.11.16. Second plastic operation. Excision of scar on the 
t cheek and occlusion of the gap with local fat-slide, left ala of nose freed and brought 
down three-quarters of an inch in the middle line. 

PLASTIC OPERATION. 12.1.17. To reinforce left ala. The columella dissected up 
>m lip and short flap made. Existing ala freshened and undercut, and columella 
turned upon itself and sutured along line of ala. The split base of columella sutured 
to form a new one. 



Fra. 489. Condition on admission. 

FIG. 490. After cheek plastic. 

Fio. 491. Profile view of new ala. 

FIG. 492. View from below, showing deficiency 
of columella. 


CASE 10 

This case, although an incomplete one, is shown for various special reasons. 

In the first place, it is one of two examples of a star-shell burn in our clinic, and re- 
presents the effect of a magnesium flare fired from a Verey Light pistol at close range. It 
is the more deplorable because of the foolish nature of the accident. The effect would 
appear to be due to two causes, one the force with which the projectile penetrated the 
face, and the other the burning effect of the magnesium on the inside of the maxilla. 
Practically the whole of the interior of the nose was burned away. 

The floor of the nose, the septum, the left lateral nasal wall, the left alveolar process, 
and the floor of the left antrum were found involved in the destruction. Excessively thick, 
non-yielding scar tissue bound the upper to the lower jaw on the left side. The skin lesion is 
apparent in the photograph, figure 493, and includes a portion of the upper lip, cheek, left 
ala, and a portion of the nose. 

This case, the only one the author has treated by the Tagliacotian method, was un- 
finished owing to the death of the patient from a severe concurrent disease, and the record 
of the case is not as complete as the actual result. The method of forming the ala is of 
considerable interest ; a piece of cartilage was taken from the antihelix of the left ear and 
inserted in the left arm with the skin tucked underneath it to form an ala. This was trans- 
ferred to the nose after suitable interval, the arm being held in place by plaster bandages. 

However, considerable suppuration of the flap occurred during this stage, which may 
have been caused by frequent contamination with vomitus. Nevertheless, it was success- 
fully grafted over the cavity in the face, and the new ala, although not in position, was 
obviously a satisfactory one. A subsequent minor operation resulted in its being dove- 
tailed and modelled into the nose, giving a still better appearance with a great promise 
of an {esthetic result. On the third day following this operation a very severe attack of 
erysipelas occurred, followed by a small amount of local gangrene and septic broncho- 
pneumonia, from which the patient died in isolation hospital. 

There is no doubt that more time should have been allowed to elapse between operations, 
but at that time conditions were such that it was rather important to proceed as quickly 
as possible with cases, one's judgment notwithstanding. 

Fid. 493 -Effect of Verey Light injury. Note small hole externally, with extensive destruction of the, maxilla. 



Fio. 494. The new ala formed on the arm by tucking skin 
round a piece of ear cartilage. 

Fio. 495. Transference to nose. 

Fio. 496. The good shape of the new ala is seen. lt_was subsequently brought into a more central position. See text. 



CASE 452 

This is a case of a R.A.M.C. (Field Ambulance) orderly who lost the tip of his nose by 
a piece of shell. The loss is minor compared with the other cases, and the treatment meted 
out seems radical. 

The results, however, in the author's opinion, justify the procedure, and give a more 
satisfactory appearance than any cheek-flap would have done i.e. the French method. 
There are one or two examples of tip, alas, and columella being made by French method 
showing excellent results, notably, a case of my colleague, E. Seccombe Hett, F.R.C.S. 

\Vhere the loss is one-sided and very small I think this is probably a better operation 
than the Indian method, but where the loss is both-sided the frontal flap method appears 
to give the best results. 

Details are appended : 

21.2.18. Operation. Rhinoplasty, tip and part alae of nose. 

Method. Indian, plus inverted skin-flap. 

Inverted skin-flap A outlined from dorsum of existing nose sewn B to B' and C to C'. 

In reflecting flap A, a little bit of cartilage was taken from the septum so as to give 
stiffening to the tip and columella. The raw area thus made, represented in diagram 2, 
was covered by a shaped flap taken from the right of the forehead and swung into place. 
This was cut the exact shape of the raw area as measured by tin-foil. The pedicle was very 
long and very narrow. Bridge flap variety. Sutured into place. 

Satisfactory appearance. The raw area in the forehead was almost completely closed. 

BB' cc' BB' 

Fio. 497. Flap A is the inturned flap, of which the points S and C are sutured at B' C'. 

Progress Satisfactory, except slight haemorrhage from bridge portion of pedicle. 
; ^?;7*!;? ntal fla P cut thin ' including only part of Frontalis muscle. 
6.3.18. Operation. Return of pedicle. Osteotomy nasal bones. 
Result. Satisfactory. 

25.C.18. Operation. To rectify columella, which showed a perforation or window on 
1 view Local anaesthetic. A small flap on each side was brought forward from 
the remains of the septum and sutured to the existing columella 
Result. Satisfactory. 



FIGS. 498 and 499. Indian mutilation type. The healed condition. 

Fio. 500. Shows the frontal flap with its 
pedicle lying over the glabella. 


FIGS. 501, 502, and 503. Result after return of pedicle. 




Four cases of injury of the lower third of the nose have been treated on a 
new principle. Case 145 which has just to be described was a failure, but the 
other three have all been very useful restorations. The principle of the opera- 
tion is exceedingly difficult to explain. It is suitable only for losses of the 
lower third involving tip and one ala. It is not suitable if the other ala has 
been destroyed. First, the distance from the existing nasal bridge to the ideal 
tip is measured and a piece of cartilage of that length and of proper diameter 
taken. Commencing half-way up the forehead in the middle line, an incision 
is carried down through the skin on the less damaged side of the nose, which 
incision is stopped at the lower border of the nasal bones. A similar incision 
is made on the opposite side starting from the same point, and this V-shaped 
flap reflected. Underneath this is inserted the piece of cartilage, which is pushed 
down to the base of this flap. The flap is swung back into position and the 
first stage is complete. The second stage, after three or four weeks, consists 
of the raising of the same flap through the same incision, but in the flap is included 
the previously imbedded cartilage. The incision on the sound side is now 
deepened, and as the knife leaves the border of the bony bridge it is carried 
through all thicknesses into the nasal cavity and continued down close to the 
septum. On the side of the loss, the incision is carried down, gradually getting 
wider until it extends outwards and downwards into the check. By carrying 
the knife beneath the cartilage, it is undercut until the lower border of the bony 
bridge is reached. Here it is turned directly downwards into the nose, and all 
tissues are cut through, including the septum. The whole flap now consists of the 
remains of the columella, the affected ala, the long skin-flap, and the cartilage, 
together with a small portion of the anterior part of the septum. Its blood 
supply comes through the columella and septum, and through the lateral pedicle 
on the affected side. It is freely movable, and the lower extremity of the 
imbedded cartilage, with the skin over it, is made in the position of the new tip. 
The upper end of the cartilage now slips off the bony bridge and is abutted on 
its lower aspect. Similarly, the mutilated ala comes to lie in a position of a true 
ala, skin suture is effected in this new position while the sound ala is sutured 
to the new tip. 

In reviewing this method it is obvious that there is a certain amount of raw 
area beneath the cartilage at its upper end and beneath the flap just above 
the new ala. More by luck than by judgment, the cartilage has not become 
infected nor is the new ala seriously contracted in my cases, and the raw areas 
have Ix-romr epithelialised. It is quite feasible, should one be doing this opera- 
tion again, to provide the necessary lining for these raw areas. 



CASE 111 

This was the second case of total rhinoplasty attempted. This terrible injury in- 
volved destruction of the entire nose, the middle half of the upper lip, the pre-maxilla, 
and the lateral nasal processes of the superior maxilla. There was also considerable loss 
of the soft tissue of the cheeks. 

When he had sufficiently recovered from his wound, the upper lip was remade by descend- 

A. Periosteum. 
B . Rib cartilage. 
C . Skin flap.. 

The periosteum wa,s put round the cartilo-ge 
and wa.s sutured below. 

Fia. 505. View of the forehead from above. 

Fio. 504. The healed condition after the palate 
remains had been returned by dental appliance. 

ing lateral flaps, the mucous membrane being advanced to complete the red border. This 
was moderately successful, but there was an ugly droop at each corner of the mouth. 

The next stage was performed some three months later, on 17.4.17, and included the 
imbedding of a cartilage rod beneath the periosteum of the frontal region. The periosteum 
was made partially to surround the cartilage. 

There was some slight suppuration following this graft, about the fourteenth day 
after the operation, and a small incision near its extremity had to be made. The condition 
rapidly cleared up, but the cartilage and new nose were not brought down on to the 
face until some five months later. When the flap was outlined and raised from the 
forehead, it was found that the cartilage that had been there so long had made a bed for 
itself by pressure atrophy, and force had to be used to raise it from its bed. A large 
portion of the under surface of the cartilage, especially near the attached end of the flap, 
would therefore have been exposed to the nasal cavity, if one had not turned down the 




FlO. 506. Shows result of lip operation and the 
cartilage imbedded in the frontal flap. 

FIG. 507. Diagram of the rhinoplasty. Note : the 
little flap D was all that was provided in the way of 
epithelial lining. Hence the indifferent result. 

small skin-flap, marked D in the diagram, to cover this portion. (It is interesting to 
note that at this stage the author had not fully realised the significance of the skin-lining 
to the new nose, and was labouring under the delusion that a periosteal layer between the 
cartilage and the nasal cavity was an adequate protection from sepsis.) This patient had 
a very narrow forehead, and, in avoiding the hair-line, the flap was not cut big enough. 
It should be noted that an extra large flap was necessary in order to cover in the cheek 
defect as well. 

Considerable difficulty was experienced in fitting this nose into position, and the im- 
mediate result was only moderately satisfactory. 

In order to imitate the natural prominence of the pre-maxilla, the tissues of the cheek 
were incised, at points A'. Relaxation sutures held these two flaps together, and this 
manoeuvre deepened the upper lip. Relaxation sutures were also passed from one cheek 
to the other, underneath the new nose. 

A slight intra-nasal discharge followed this operation, but it cleared up with syringing. 

The pedicle was returned on 4 . 10 . 17, and into the base of the nose a small homologous 
cartilage graft was superimposed on the previous cartilage. Over the undisturbed granu- 
lations in the forehead a large Thiersch-graft was laid, and bound firmly into position by a 
covering of paraffin wax (No. 7), gauze and bandages. 

The after-history of this case is unsatisfactory except as regards the skin-graft, which 
healed perfectly. The homologous cartilage did not take, and infected the imbedded 
cartilage. Six months later all the cartilage appeared to have been absorbed, which disaster 
is due to its becoming exposed to the nasal cavity on its under surface. 

This case is described in order to point out various mistakes of which one has become 
cognisant after the events. It is a mistake to put the cartilage under the periosteum. 
It is a greater mistake not to line the new nose with some form of epithelium. The homo- 
logous secondary cartilage graft was an injudicious procedure. 



FIG. 508. Two days after the rhinoplasty. The 
author does not now use rubber tubes. 

FIG. 509. After this stage the pedicle was 
returned and the forehead successfully grafted. 
The nose, however, owing to the lack of epi- 
thelial lining mentioned in the text, underwent 
considerable diminution in size. 

This case is also of interest in that it shows the difficulty of making the nose on an 
abnormal bed. Had the nose been a good one, it would still have been set quite 1 in. too 
far back, owing to the loss of the pre-maxilla, which loss was not greatly overcome by the 
flap manoeuvre carried out at the total rhinoplasty. It would have been better had one 
adopted the suggestion of Captain Fry, our chief Dental Surgeon, of separating the new lip 
from the maxilla and inserting a dental plate prior to the operation for the nose. This 
can, of course, still be done, and by methods that are described in later cases it is yet possible 
to procure a satisfactory surgical result. 

Another case done by my late colleague, Captain Aymard, at the Cambridge Hospital, 
Aldershot, should be recorded, as it is an evidence of an effort at perfection in rhinoplasty 
marred by the want of a skin lining. 

It was a case similar to the one just described, but it lacked the lateral loss which 
complicated Case 111 ; that is to say, the bed on which to put the nose was normal. Captain 
Aymard, with the assistance of the sculptor. Lieutenant Edwards, made a model of the 
ideal nose in plasticine, and then reduced this by the thickness of a forehead flap. The 
remains of the mould were then cut into sections, and cartilage to correspond with this 
undcrmould of the nose was cut from the costal region. 

In order to get the exact shape more than one piece had to be used. These were 
stitched together with catgut. This composite block of cartilage was then inserted between 
the skin and aponeurosis of the frontal flap. The appearance for some weeks was remark- 
ably good, but, owing to the lack of epithelium on its under-surt'ace, slow ulceration of the 
cartilage occurred, with subsequent flattening and contraction of the new nose. 


CASE 145 

This is interesting as an attempt to perform the author's modified operation. It 
partially failed, hut the imbedded cartilage was of service later in the case, when a modified 
Keegan-Smith operation was carried out. 

The modified operation was different in this case from any of the three next 
described, Nos. 140, '298, and 300, in that the pedicle was bilateral, whilst in each of the 
other three cases the pedicle was unilateral. 

The reason for this difference is that this Case 145 has its anterior nares on the same 
level each side, whilst in each of the other cases one was at a higher level than the other. 
In comparing his result with the others, one notes objectionable features in the use of double 

The result was fairly satisfactory. The lengthening of the nose is seen in photo 

(fig. 513). The imbedded car- 
tilage is fairly evident. An 
attempted columclla from the 
upper lip at the same time 
broke down. 

Photos of the result of 
this operation were taken a 
year after, and it then had to 
be decided whether a corrective 
operation to complete the 
rhinoplasty on its existing 
basis should be performed or 
whether the method should be 
altered. The latter course was 
adopted, and the condition 
was now really only one of the 
Indian mutilation type. 

The turned-down skin-flap 
to line the new tip and ala? 
was made to contain a portion 
of the cartilage of the previous 

The turned-down flap was 
partially split so as to get the 
Smith variety of the Kcegan 

The exciting part of this operation was the frontal flap, because, as the diagrams show, 
the scar of the first operation ran very nearly across the pedicle of the frontal flap. Not- 
withstanding this, the blood supply was quite satisfactory, and the procedure appears to 
be justified. 

This particular patient has a very poor resistance to infection, and at the return-pedicle 
operation a considerable sepsis of the forehead wound occurred. A skin-graft to make 
good the area denuded of epithelium failed to take. 

It will be interesting to note that several plastic operations had been attempted on 
this patient prior to his admission to our clinic. Twice he has had his arm tied to his head 
and an Italian operation attempted. Both failed. 

Fio. 510. Incisions for the rhinoplasty. 



FIGS. 51 1 and_512. The injury. Loss of the lower halt of nose. 

FIG. 513. Indifferent result of 
special method (used in the 
next three cases described). 

FIGS. 514, 515, and 510. Result of making new|tip and alaj by double epithelial flaps and cartilage. 

See diagram and text. 



CASE 140 

Thr tvpe case is No. 140. Loss of the tip commencing just below the bony bridge 
and extending down to the base of the columdla. More of the Iclt ala reg.on was lost 
than on the right. Bv an incision which is shown in the diagram a sk.n-flap was turned 
down from the forehead. The incision was made on the right lateral aspect ol the nose 
from the junction of the ala to remains of septum, up to the inner margin of the right eye- 
brow, and then to a point in the middle line of the forehead, about 2m. above the root 
,,f the nose. The skin was undermined and raised off the bridge of the nose and a flap 
of periosteum 2 in. long by 1 in. broad was reflected downwards from the forehead, being 
left attached in the glabellar region. 

This periosteum, therefore, came to lie underneath the raised flap of skin and 

the existing nasal bridge. , . 

A piece of cartilage about If in. in length was now taken, and wrapped in this peric 
teum. The skin-flap was placed over this imbedded cartilage. 


FIG. 517. Stage 1. The incision for the insertion 
of the cartilage. 

FIG. 518. Stage 2. The same incision extended 
so that the advancement can be made. 

Some two months later the second stage was performed. It consisted of an incision 
along the right side of the nose in the same line as in the previous operation. At its lower 
end the knife was carried deep into the nasal cavity. A corresponding incision was made 
on the left side, commencing from the mid-point of the forehead and descending along the 
line of junction between nose and cheek down as far as the commencement of the naso- 
labial fold. This flap of skin was then raised, commencing from above. At the point 
where the cartilage was met the knife was carried deep, so as to raise it imbedded in the 
skin-flap. At the point where the existing bony bridge ended the knife was carried 
deeply into the nasal cavity. The blood supply to this flap, thus detached, came from 
tlie whole thickness of the left ala and columclla. 

The whole flap and cartilage could now be advanced downwards, the cartilage producing 
a satisfactory support to the new tip. The upper end of the cartilage graft was inserted, 
partly under and partly over, the nasal bones by splitting its upper end. The left nasal 
opening now formed a satisfactory new left ala, and was brought by this manoeuvre to the 
same level as the right one. 

The only difficulty in suture occurred at the' re-entrant angle on the left side between 
the eye and the nose. A small flap from the left upper lid was turned down to complete 
the closure. 

Secondary corrections of the tip were performed later with satisfactory result. 



In criticising this method, as evidenced by this particular case, its defects would appear 
to be that the tip, in this method of swinging it down, becomes somewhat depressed. It 
gave a by no means displeasing effect to this particular patient. 

FIG. 519. The healed stage. 

Fio. 520. Profile. 

FIG. 521. Result of the advancement. 

Fio. 522. Profile. 



CASE 298 

The next case, No. 298, was of the same type, but of a very much smaller degree, and 
on this occasion one tried to get over the difficulties above-mentioned Avith Case 140 by de- 
signing the flaps differently. The skin was advanced from the cheeks and not from the 
forehead. The disadvantage of this method became apparent later, as there were two 
scar-lines running across the middle line of the new nose, whereas, with the long pointed 
flap, the skin was not so marred. 

An effort to improve the tip was also made, and a shaped piece of cartilage (fig. 524) 
was inserted through a right lateral incision, well shown in the photograph (fig. 527). 

Here, again, the left ala was situated at a higher level than the right, and the imbedded 
cartilage was swung down with its blood supply from the columella and left ala (flap X in 

The right ala was sewn to the nose-tip, and the area of skin along the bridge of the 
nose caused by the descent of flap X was made good by a lateral advancement flap A 
from the right cheek and a long relaxation cut B C on the left cheek. The early result 


FIG. 523. Cartilage was imbedded under X. X is then advanced with its 
cartilage. The gap is made good by lateral advancement of flap A. 

FIG. 524. Shape of the cartilage 

of this nose was not good from a cosmetic point of view, and the tip could not be brought 
down sufficiently owing to a lack of sufficient stalk to the cartilage with which to gain its 
purchase from the existing septal bridge. The tip has a tendency to be blue. 

Eight months later the condition was very much improved, and a following corrective 
operation was performed. 

1. Excision of the redundancy of the columella, the cartilage in this columella being 
removed and inserted in the depression in the nasal bridge. The tip, which was too fat, 
especially on the right side, was reduced by excision of a piece of cartilage from this aspect. 

In order to produce a roundness of the tip this piece of cartilage was there inserted. 

The result of this corrective operation was very satisfactory, but the slight tendency 
to blucness in the tip has temporarily reoccurred. 

All scars are rapidly becoming invisible. 



FIGS. 525 and 526. Loss of the tip and part alae. 

FIG. 527. Stage 1 : Implanta- 
tion of cartilage. 

FIGS. 528, 52'J, and 530. Result after advancement of skin and cartilage. Note : the nose was still becoming 

thinner and more shapely when last seen. 


CASE 300 

The third of this scries was of a typical Indian mutilation type, but the left ala 
was again at a higher level than the right. The diagram shows the incision of the first 
stage at which the cartilage was imbedded. A separate piece of cartilage was imbedded 
in the left ala to fill this out. The pcriostcal bed from the frontal bone was similarly turned 
down underneath the cartilage. (Diagram 531.) 

At the second stage, performed four months later 19.10.17 a flap to the extent and 

shape shown in the diagram 
was raised with the carti- 
lage and slid down to form 
a tip. A small prolonga- 
tion over the left eye 
brought over the frontal 
flap not in diagram was 

^u v\V'\\ made in order to overcome 

J WM--- N '~* thc difficulty of the rc- 

// OT%T Periosteum entrant angle when the 

H~8Wn advancement had taken 

H- Cartilage . T . 

place. It was satisfactory 
in filling the gap, but was 
lost through failure of blood 

The immediate result 
was good, but there were 
slight irregularities, due to 
the failure of the small flap 
to live. 

All these three cases have shown good results, but each one has shown 
certain difficulties of a minor character which have not been solved. The 
operation has the very great advantage of producing no large or marked scars 
anywhere, and those that are made are in the lateral aspect of the nose and in 
the midline of the forehead. 

In view of the series of cases done by the Indian method it would seem 
that this operation, if capable of further improvement, would supersede the 
Indian method for certain types of minor loss of the tip and alee. 

One disadvantage not previously noted in regard to this operation is, that 
the new tip tends to be cold and a little blue, due to the fact that the mutilated 
tip, when healed, has a considerable amount of scar tissue over it. Time has 
largely rectified this in my cases. 

The author has used this method only on one other case (Case No. 145, q.v.), 
but on this type the operation is contra-indicated, as the loss is too severe, and 

The later examination showed a quite satisfactory result, except that the left ala was 

somewhat retracted, causing stenosis. Ihe columella also was not central or suflicieiitly 

Cartilage from the antihclix of the left ear was imbedded to strengthen the 

t ala ; at the same time scar tissue was excised and skin tucked in to make a better vesti- 

The columcllar attachment was divided above and re-sewn in a more central and 



permanent position. The final result was good, almost as good as if a successful inturned 
and frontal flap had been made in the first instance, and there was, in addition, the great 
advantage of a minimal secondary deformity. . 

Fios. 532 and 533. Loss of tip and part ala\ All the free edge of the left ala is destroyed. 

FIGS. 534, 535, and 53fi. Result of advancement operation and minor corrections. (Author's method.) 



CASE 583 

This is really a transition case from our previous group, and there is hardly more than 
half of the nose gone ; in addition, he has the enormously valuable remains of the akc. 
There is only one feature about the case which is different from the type of operation, and 
that is in relation to the external flap, which was cut and arranged differently, by a new 
method, around the tip and al;e. There is really very little else to discuss about this case, 
and the good early result is only that which is to be expected. The external flap was cut 
differently for the following reasons: (1) One has realised for a long time that it is un- 
reasonable to expect to be able to make a perfectly fitting covering for the nose out of one 
flap a tailor's cutter, if he were asked to clothe a nose, would not make his suit out of 
one piece of cloth ; there would be some accessory pieces for the delicate curves of the 
nostrils and vestibule. With this idea, the author decided to make the columella and lobule 
out of two lateral flaps brought together and sutured down the middle. Situated laterally 
to these flaps two further pieces were cut, one on each side, which were curled in upon 
themselves and were to represent the portion of the ala? that had to be made. One feels that 
a new principle underlies this new method. Something similar was successfully attempted 
in Case '203, where an excellent tip was also produced, and it is probable that a modification 
of the frontal flap on some lines similar to these two cases will eventually be made. Another 
frontal flap similar to that of Case 583 has been made, but the case K in too early a stage 
to be sure of the final result. Operation details are appended here : 

18.7.18. Operation. Preliminary intranasal work with implantation of cartilage. 
Cartilage from 7th and 8th costal cartilage. Skin incision extending from inner side of each 
eyebrow downwards to just above the ala on either side. 

Skin undermined and cartilage implanted. The incision was made in this way so that 
the flap developed its own blood supply. The right ala was separated by a curved incision 
running through the alar furrow, and the skin and mucous membrane sutured together. 

FIQ. 537. Loss of lower half of nose. Nasal stenosis. 

Fia. 538. Profile on admission. 



The same procedure for left ala. Incisions were carried upwards on either side of the septum. 
A small V-shaped portion of the septum was excised in its lower portion, and the skin 
was sutured to mucous membrane. Tube covered with vaseline gauze was replaced in each 

Note. Great difficulty was experienced in sewing the skin over the cartilage, es- 
pecially on right aspect. A small portion of cartilage remained exposed. Kesult : very 
satisfactory. The exposed cartilage was not infected, and was rapidly covered by epithelium. 
Nasal airway established. 

Fio. 539. Result of the important first stage. (1) Also replaced j (2) airway established ; (3) cartilage 
imbedded over glabella and bridge of nose. 

17.10.18. Operation. (2nd Stage.) 

1. Glabella flap swung down with its contained cartilage. 

2. The exposed portion of the septum was incised from above downwards, thus making 
a slice which served as a support for the columella. Its back surface was covered by the 
tip of the turncd-in glabella flap. The alse remains were freshened and partly sutured to 
this same flap. 

A bifid frontal flap of special design was brought down from right forehead. 

The points are : 

The lobule and columella were made by bringing two lateral flaps together while two 
further lateral flaps were turned in on themselves to complete the remaining portion of 
the ala?. The tips of these inturned flaps were sutured to the original glabella flap. 

The antero-latcral aspect of the columella was denuded of epithelium to receive the 
above-mentioned columella flaps. 

Result. On the table looked very satisfactory. No attempt made to close or graft 
forehead wound. Later : satisfactory, but the inturned flaps to complete the ala? broke 
away a little, which somewhat spoilt the line of the new ala;. 

18.1.19. Operation. Pedicle returned to forehead. Scar tissue excised, and a whole 
thickness skin-graft applied to remaining raw area on forehead to readjust hair-line. 



FiO. 540. Cast taken after first operation, showing incisions for (1) inturned skin-cartilage flap ; 

(2) special bifid frontal flap. 

I'm. .11 1. 1. The skin cartilage llii| 1 1ms brcn in tun in I. 

I h. i-il^o; of nl;i' iiiul columella freshened. :!. The 

liilid frontal flop is about to be sutured into place. 

Note the formation of tip and columella by the two 

- a. 

FIO. 542. Suture of the frontal (lap. Note the 
inturnrd portion at A and D to complete vestibular 
rpil lirliuin. 

Note. The suture line of the forehead is incorrect. 
See text. 



FIGS. 543 and 544. Profile views soon after return pedicle operation. The Wolfe graft to the forehead 

has not yet healed round its edges. 

FIGS. 545 and 5lG Early finals. 




CASE 183 

This patient entered the clinic with a sub-total loss of the nose. The upper portion 
of the bony bridge remained, whereas the lower part was a mass of skin and cartilage, the 
debris of previous plastic operations. There was also a " mucous membrane columclla," 
the redness of which completed the unpleasantness of the effect. Marked nasal obstruc- 
tion was present. 

It was decided to swing down a flap of skin which contained cartilage, to form the 
lining of the nasal tip and vestibules, at the same time to cut away the mucous membrane 
columella and to re-establish the airway. This operation was performed on 14.2.18. 
It may be divided into three stages : (1) The mucous membrane columella was excised ; 
(2) the triangular flap was cut from the existing nose and swung downwards, skin surface 
inwards. The extremity of this flap, which formed the back of the columella, was stitched 
to a raw area on the upper lip made for its reception. In order to give support to the new 
tip, the cartilage that had previously been imbedded was sectioned from above downwards, 
until its extremity could be stitched to the raw surface of the first flap in the situation of 
the tip. A portion of the cartilage was also left down the columella. There was a natural 
tendency for the cartilage to spring upwards. (3) Ihe whole raw area was covered by a 
forehead flap carried on a small pedicle, the exact size of which is seen in the appended 
diagram. The forehead was closed by approximation, a circular silver wire suture being 

used. Healing was exceptionally good, and save 
for a breaking away of the upper lip from the new 
columella which was probably due to the spring 
of the cartilage no untoward result occurred. The 
pedicle was returned four months later and the 
columella reattached to the upper lip. 

Further adjustments, under local aiuesthesia, 
were made on two later occasions, and a small 
piece of cartilage, from another case, was inserted 
through the columella to give more prominence to 
the tip. 

The patient was discharged on 21.1.19, the 
nose looking very natural and having a good 
airway. On cold days, or when exposed in a car, 
this nose gets blue at the tip, but not more so than 
a great number of natural noses. The suture line 
between the new nose and side of the cheek is 
almost imperceptible; entirely on the left, and 
nearly so on the right. 

The history of this case teaches a lesson. 
Originally there was total destruction of all the 
supports except that of the upper part of the 
bridge, and the remaining skin of the nose was 
lying flat in front of the nasal aperture. Several 
attempts at cartilage implantations and small 
cheek-flaps had been made with indifferent results 
prior to one's taking over the case. In addition, a 
mucous membrane columella had been brought 
from the upper lip in the region of the nasal 

In view of our later methods, all this diflicult work that had been performed was on 
entirely wrong lines. The addition of the pouting mucous membrane columella had not 
OTlly a horrible appearance, hut also seriously blocked the airway. 

Fio. 547. Composite cast showing incisions 
for rhinoplasty and the excision of the mucous 
membrane columella that had been made prior 
to admission. 


FIGS. 548, 549, and 550. Condition on admission. Cartilage had been implanted in the nose to raise the 
bridge without satisfactory result. A columella had been made out of lip mucous membrane. 

FiQ3. 551, 552, and 53;i. -Pictures of tho rosult. Tho pedicle in"jthis case was returned to the forehead, the 
balance of the raw area of which was closed by approximation and healed scar. 


CASE 385 

This case is interesting in that it is a stepping-stone to much of the present-day rhino- 


Previous to this, one designed the " Vallancey swing " (for the pug-nose type) without 

quite realising its significance. 

This was the first considerable loss of the nose repaired in our clinic by shaping inturned 
flaps, and the support was provided by a removable mechanical appliance resting in an 
epithelial cavity, while the outside covering was of the usual type. This apparatus was 
designed by the late Captain Robertson and is illustrated. 

In reviewing this case, one is sure that a better result would have been obtained had 
cartilage been provided in the inturned flap and for the alae. In our experience, any form 
of intranasal support is liable to produce chronic irritation and stenosis. These two fleshy 
flaps making the nose gradually took up a position shown in fig. 560, which is considerably 

lower than immediately after the operation. In addition, 
epithelial grafts had to be applied to the anterior nares to 
give stability to the airway. 

The patient is quite satisfied with the result, and it is 
certainly an interesting case so far as the later develop- 
ment of rhinoplasty is concerned. One year after the 
restoration, the junction of the new nose and cheek is 
almost invisible, and the colour of the nose is so natural 
that its deficiencies in form are greatly minimised. It 
should be noted that a very narrow pedicle was employed 
for the frontal flap. Secondary deformity of forehead 
whence the flap was taken is minimal, while the airway is 
sufficient without being free. 

25.9.17. Operation. For establishing nasal passage. 
26.10.17. Nasal splint, with tubes, fitted. 
9.11.17. Previous operations unsatisfactory. Nasal 
stenosis present. Operation for cure. 

1. Circular incision in a free manner round nasal 

2. Impression of aperture taken in dental wax. 

3. The grafts were then laid over the parts which were 
in contact with the raw surfaces. 

4. The mould and grafts were then placed into position 
and held there by strapping. 

5. Two airways were made through the model. 
Result. Perfect epithelialisation, except in the floor of 

the left nasal passage. A very good quality of skin was 
produced on right side. Slight stenosis of left passage re- 
mains. General result satisfactory. 

Note. This method is an adaptation of the inlay, and 
might be called a semi-open epithelial method. Note 
the disadvantage on the floor of the nose, owing to 
secretions collecting at that spot. 

30.1.18. Operation. Rhinoplasty. Sub-total, 1st stage. (Oil ether.) 
Reformation of lower two-thirds of the nose by means of double epithelial flaps sup- 
ported by temporary vulcanised splint (splint made beforehand, and accurately fitted the 
floor of the nose). The skin of existing portion of nose was turned down at a flap A, B, 
A, on a hinge represented in diagram by dotted line, which, in reality, was the margin of 
the existing nasal aperture. 

This flap, when turned down over the splint, formed the skin lining for the new nose, 

Fio. 554. Vulcanite intranasal 
support in three pieces, over which 
the double epithelial flaps were 
moulded. This apparatus was 
made by the late Captain E. G. 
Robertson, attached R.A.M.C. 



including the ala and the back of the columella. Portion of the lip skin A was turned 
upwards to meet B and to complete the posterior lining of the columella. A model of 
the raw area in stent was then made and outlined on the forehead. The flap was cut and 
swung down into place, completely covering all raw area. 

It will be noticed that the extremity of the frontal flap was sutured into the upper lip. 

The total appearance was very satisfactory. Healing by first intention, and exception- 

Fio. 555. Diagram of the inturned flap B and of the forehead flap. The hinge on which B was turned 

over is indicated by a dotted line. 

ally good scars obtained on the lateral nasal aspect. Stitches removed third and fourth 

The pedicle was a bridge pedicle. Treatment of central frontal gap by silver wire 
suture. No skin graft. 

12.2.18. Operation. 2nd stage. 

Bridge pedicle, separated from grafted portion, returned to forehead. A cut was made 
into this pedicle to elongate it. The cut nasal end of pedicle was imbedded into the nose. 



FIG. 556. The injury on admission. 

FIG. 557. Profile. 

Fio._558. After establishment of nasal airway by excision of scar and Thiersch graft. 



FIG. 559. Result. Pedicle returned to forehead. 

FIG. 500. Profile. Note : no cartilage support was used in this case, which would 
undoubtedly have improved its lines. 


CASE 632 

This gunner lost the lower two-thirds of his nose by gunshot on 15.1.18, and was 
admitted three months later to the clinic. 

There was almost complete stenosis from scar tissue, and the first necessity was to 
establish a breathing passage. This was kindly undertaken by Major Justin M. Waugh, 
M.R.C. (U.S.). On the left side some remains of the vestibule could be utilised in the 
repair. Shortly after that Major Waugh was called to other fields of activity, and one 
established the airway on the left side on the visual lines, having given up the idea of using 
these small remains of vestibule. At the same time, cartilage was imbedded into the pro- 
jected " turned-in" flap. A further thin rod of cartilage was implanted in the left cheek, 
which was a new method of making the ala. The idea was that a combined skin and 
cartilage flap should be turned in as a lining to the vestibule and a support to the ala. It 
is the same principle as the Vallancey Swing. The natural spring of the cartilage should 
prevent any atresia of the nares. A most satisfactory ala was thereby secured. A special 
design of the frontal flap was made in this restoration. The tip-columella portion of it. 
was cut considerably longer than necessary, and when brought into position on the new 
nose this redundancy was dealt with by making the flap curl back upon itself over the tip. 
Stitches were put in laterally to maintain this fold. It gives a bizarre appearance at the 
time of operation, appearing like a square projection at the end of the nose ; but one felt 
sure that this would round itself off. As the photographs show, a most excellent tip was 
the result. 

This case, No. 583, and another case not illustrated, all show definite attempts to 
produce a new and better kind of lobule. Details of operations follow : 

29.6.18. Operation. Establishment of nasal airway. Result is satisfactory on right 
side. Healed well. 

10 . 8 . 18 . Operation. (1) Cartilage imbedded into root of nose for later " swing down." 

Fio. 661. Loss of lower two-thirds of nose. 
Complete atresia of nose. 

FIG. 562, Profile showing the loss of contour. 



(2) Small rod of cartilage was imbedded in cheek on left side for later support to left ala. 
Remains of right ala freed and brought down into position. Skin sewn to mucous membrane 
all round nasal aperture. 

Result. Satisfactory. 

10.10.18. Operation. (1) Glabella flap, with its contained cartilage, swung down 
inverted. Extremity of flap split into two halves, which were twisted raw surface to raw 
surface to make lower part of columella, a small circular area in upper lip being bared to 
receive it. (2) Remains of right ala freed and its edge pared. (3) Small flap, with contained 
rod of cartilage, turned-up skin surface inwards to form vestibule and support of left ala, 
sutured to the skin of flap 1. 

Note. The cartilage in flap 1 was now sticking out very prominently, and a portion 

Fio. 563. Shows clearly the" establishment of the 
nasal airway by scar excision and suture of skin to 
mucous membrane. A cartilage rod has been inserted 
over the bridge of the nose and glabella, and a small 
lamina into the cheek for the ala support. 

Fio. 564. Incisions for the next stage : the two flaps 
containing cartilage are inverted. The right ala 
stump is advanced and the forehead flap brought down. 

was excised from the extremity. The lining membrane was completed by catgut suture 
of these three component flaps. 

(4) Flap of required size cut, brought down from forehead. 

Note. Left ala looks exceptionally well. 

A special doubling of the extremity of the forehead flap (see diagram) was carried out 
with the idea of giving more prominence to the tip. 

The immediate effect was bizarre. Forehead closed by approximation. 

24.10.18. Progress. Satisfactory. Tip contracting into very good shape. 

The pedicle has not yet been dealt with owing, amongst many other things, to the 
present influenza epidemic. It is proposed to deal with it by excision, then by replacement, 
with the addition of a whole-thickness graft in the upper portion of the scar to allow the 
eyebrow to descend. 



Fio. 565. Lateral view before Fio. 566. Suture of the inturned flaps FIG. 567. Lateral view 
covering flap is brought down. and advanced right ala. with covering flap. 

Note that the split ends of the inturned bridge-flap are turned together so 
that their skin surface forms the columella. 

Fio. 508. Suture of the frontal flap. The forehead was closed by approximation 
the exact lines of this are not indicated in the diagram. 



FIGS. 509 and 570. Views of the nose with the pedicle in position. 

FIG. 571. Pedicle returned. FIG. 572. Profile. Compare with original. 

Note the slight notch in right ala, which was due to an error in diagnosis of the amount of ala lost. 
The new method of making the left ala gave an excellent result, as shown by this case. 


CASE 365 

The first photograph shows early result of a very serious injury. In addition to de- 
struction of the left eye, and deformity of the upper eyelid, the lower two-thirds of the nose 
was destroyed as well as the pre-nuixilla and the greater portion of the upper lip. There 
remained about one-third of the upper lip at the left corner. The condition on arrival, 
some twelve days after injury, and that when all wounds were firmly healed, arc shown in the 
photographs. On 29.11.17 an operation was performed, as a first stage, on the upper 
lip, to construct a bridge on which the new nose could be made. 

As no photos of this intermediate stage are available, this operation is not illustrated. 
It was intended only as a partial repair of the lip. As regards the rhinoplasty, the 
principle of building a double epithelial nose over a mechanical intranasal support was the 
one employed, in the hope that more definite shape might result. 

The operation was planned on a plaster cast. Into the nasal aperture was fitted an 
undermould of the new nose, which was made in hardened wax, having a breathing tube 
inserted in its middle. This apparatus was constructed under the direction of Captain 
Kelsey Fry and is not illustrated. Over this undermould were swung, first a flap from 
above to line the bridge portion and back of columella, and, secondly, two lateral skin- 
flaps of special design to line the new ala, the end of the central flap being attached to a 
small skin-flap turned upwards from the upper lip. When this had been carefully sutured 
together, a piece of cartilage was taken from the rib and a piece of the necessary shape was 
sutured centrally to the remains of the nasal bones. Over the whole was brought a frontal 
flap. No skin grafting was carried out. The pedicle of this frontal flap was of the imbedded 
variety and not bridged over healthy skin. 

The result of this operation was very satisfactory. Slight delay in healing occurred 
round the margins of the ala, a spot that frequently heals with difficulty. 

The mould was retained for some ten days, at which time it was unwisely removed. 
This removal allowed the tissues to thicken on the under-surface of the cartilage, and fill 
in the cavity ; at the same time, a fibrotic process commenced around the ala and, to one's 
disappointment, this result was marred by nasal stenosis, requiring a definite operation 
for cure. 

A special reimplantation of cartilage was made eight months later, in which one central 
rod was supported by two ala rods inserted through the tip. Subsequent to this, all tissues 
on the nasal aspect of these ala cartilages were excised and the columella, which was too 
short and contracted to allow the tip to rise, was cut across. The whole raw area was skin- 
grafted by thin Thiersch graft held in position by a piece of black gutta-percha. 

The graft has taken well, and the tip is now upstanding and the airway established. 
This case is completed by the insertion of an artificial columella (Captain Kelsey Fry), 
which gives support to the tip and a satisfactory appearance. There are no normal tissues 
in the neighbourhood from which a columella might be made. A better and quicker result 
would have been obtained had the cartilage been imbedded at the preliminary stage on the 
usual lines. 

Details arc appended. 

Condition. Loss of two-thirds of upper lip, lower two-thirds of nose, and pre-maxilla. 

29.11.17. Operation. For upper lip. First stage. 

At the end of the operation there still remained the provision of the skin for the right 
half of the upper lip, for which a bridge-flap seemed indicated : as in view of a later rhino- 
plasty, a descending lateral nasal flap was not indicated. The bridge flap was not attempted 
at this operation, and the raw gap was closed by drawing up the mucous membrane to meet 
the skin on the right side of the lip. 

A denture was inserted to support this lip. 

J.',.3.18. Operation. Sub-total rhinoplasty varied Indian method. 

A hard wax mould was made with the assistance of Captain Fry, in which was imbedded 
a small breathing-tube. Over this mould the new nose was made in the following manner. 
Three skin-flaps were turned inwards, one from the bridge, and two from the cheek region, 



Fio. 573. Loss of the lower two-thirds of the nose complicated by loss of the pre-masxilla and upper lip. 

FIG. 574. The healed condition. The accom- 
panying bony and lip destruction makes the 
rhinoplasty considerably more difficult. 

FIG. 575. Profile view of the lost contour. 



to complete the underlining of the new ala and back of columclla. The lateral Haps were 
of special design. These flaps were all sewn together, and the raw area thus created was 
covered by a frontal flap. Costal cartilage inserted between the two skin layers in the 
centre line. Cartilage extended from the root of the existing nose to the tip of the new 
nose. Spare piece of cartilage imbedded. The pedicle was very narrow and was imbedded. 
Result very satisfactory. The wax support was removed on the seventh day. It should 
have been retained for a considerable time longer, as thickening of the tissues and stenosis 
are occurring. 

16.4.18. Operation. Return of pedicle to forehead. No skin graft. 
3.5.18. Operation. Upper lip. Second stage. 

19.11.18. Condition. Result of lip-flap not pleasing at first, later, it settled down. 
Nasal stenosis is now almost complete, and the piece of cartilage inserted at rhinoplasty 
operation is almost flat on the face and is not acting in any way as a support. It was de- 
cided to superimpose another piece of cartilage to give more support and prominence. 

19.11.18. Operation. A piece of cartilage from store in abdomen was inserted into 
each ala to support the central rod. Diagram of method to support herewith. No attempt 
to establish airway. 

Result. Satisfactory. 

19.12.18. Operation. Excision of scar on edge of ala and of tissue beneath the alar 
cartilages, coluniella divided, and raw area beneath tip and ala skin grafted (Thiersch). 
Result good. 

Kio. 570. Diagram of operation of 19.11 .18, showing implantation of three rods of cartilage to raise and 
support the newly made pose, which had sunk on the face so that the airway was occluded. 



Fio. 577. Showing Stent to keep Thiersch graft in position. It is perforated for airway. 

FIGS. 578 and 579. Present condition ; patient wearing, temporarily, an artificial columella. 


CASE 517 

This is very nearly a complete loss of nose. This, again, was made with two skin- 
flaps without support, and one was astonished to find what a good nose resulted, although, 
of course, it was rather shapeless and there was a tendency to stenosis of the nares. Silver 
tubes were fitted to keep these nares open, but, in my opinion, they only increased the 
cicatricial contraction. It was therefore decided to allow the passage to be temporarily 
occluded and to be skin-grafted at a later stage ; also, to build up the contour of the nose 
by cartilage implantations. The first and larger implantation had the effect of raising the 
bridge without raising the tip. This was three months after rhinoplasty, and the graft 
was quite satisfactory and the nose began to have shape. A most disastrous mistake was 
made by operating again upon this patient 19 days later. On this occasion, further shaped 
cartilage for the tip and lower parts of the bridge and alae was implanted. The wounds 
healed well, the stitches were out. and at this time it appeared to be the best nose the author had 
ever made. However, on the eighth day after this operation, an abscess formed, and the 
last bridge cartilage was evacuated. When healed, the result was most unpleasant, as the 
skin was blue and wrinkled ; and I doubt whether the nose will ever be as good again. The 
cause of this failure was undoubtedly twofold: (1) operating on the patient too soon; 
and (2) irritation and late infection, probably caused by patient. 

After a considerable interval further cartilage rods were inserted for the tip and ala 
supports, the nasal surface of which it is proposed to epithelialise at a later date, to establish 
the airway. Operation details appended : 

5.3.18. Operation. Rhinoplasty, sub- total Indian method: a central and two lateral 
flaps were turned in. 

The extremity of the central one was sutured to the upper lip to form the back of the 
columella. Frontal flap superimposed. 

N.B. No support in the nose or in the new tissues brought down. 

16.4.18. Operation. Pedicle returned. 

Right costal cartilage implantation. Two large pieces put in for nose and eye. 

Skin-graft over the undisturbed granulations. A piece of whole-thickness skin the 
size of a florin was implanted. Its edges were sewn tight to the edges of the wound and a 
piece of stent superimposed to put it on tension, the edges being slightly undermined to 
retain the stent. 

Result satisfactory. Tendency to stenosis of nares. Skin-graft to forehead successful, 
pink, soft and mobile. 

8.6.18. Operation. A piece of cartilage was taken from subcutaneous store, shaped 
in form of rod and inserted from the root of the nose. Balance of cartilage rcimplanted in 
subcutaneous tissue. This implantation raised the bridge, but produced a certain amount 
of depression of the tip (comparative rather than actual). It had been decided to allow 
stenosis of the anterior nares, the passages to be re-established later. 

Result. Satisfactory. 

27.6.18. Operation. Further implantation of cartilage to give form to the tip and 
lower part of bridge and alae. Two long, thin strips were inserted through a vertical in- 
cision just below the tip. The skin of the margin of each ala was undercut with a fine 
knife as far as the cheek attachment. In these two subcutaneous tunnels the thin bits 
of cartilage were inserted. A third main piece was then inserted between the skin and the 
previous cartilage rod. which gave a very fine-edged bridge effect. An eyelid plastic was 
also performed at the same sitting. 

Result. Xo trouble occurred and stitches all out, but on eighth day nose suppurated 
and to be reopened (5.7.18). Pus and the last bridge cartilage were evacuated. Drainage. 
8.10.18. Operation. Transfer of piece of cartilage from No. 681 for future use. 

13.12.18. Operation. The above piece of cartilage was inserted in tip and bridge. 
Result" healed. 



FIG. 580. As received into hospital. FIG. 581. Profile healed. 

FIG. 582. Healed. 

FIGS. 583 and 584. Result of rhino 


:'hinoplasty and epithelial outlay for upper lid. Note the defect of the tip and 
artial naeal stenosis, for the cause of which see text. 





CASE 23 

This patient lost, by shell-wound, all the bony, cartilaginous and soft tissues of the 
nose, with the exception of half the tip and the adjacent left ala. This small remaining 
portion of the nose had not fallen back, and did not produce the pug type of nostril owing 
to the support of a small portion of the septum nasi underneath the tip, from which it ex- 
tended backward a half inch. 

This case has many interesting features. First, a natural bridge was formed by tur- 
binate grafting and advancement, the details of which are set forth later. This turbinate 
bridge formed a natural lining to the frontal flap. Secondly, additional support was given 
this frontal flap, both in regard to the bridge of the nose and the right ala, by shaped celluloid 
plates. These gave trouble and had to be removed. Thirdly, this nose was lined by (a) 
mucous membrane in its upper half, and (b) skin in its lower half. This skin was derived 
from the extremity of the frontal flap, which was tucked well into the nose. Further, no 

FIG. 585. Total loss of nose except left nla and columella. 

tendency to contraction or retraction has occurred over the period of observation, viz. 
eighteen months : at times the nose has even seemed to grow, and has been whittled down 
into its existing and now reasonable proportions. Again, cartilaginous support for this nose 
was inserted at a late stage, i.e. after the frontal flap was in position. On the first occasion, 
homologous cartilage was used, and the result was apparently satisfactory for about 
fourteen days, when the nose suddenly swelled up and about a teaspoonful of pus was 
evacuated. Three days later no more suppuration was visible, and after a period of two 
months' convalescence there was no sign of the cartilage it had obviously been absorbed. 
An autokgous cartilage graft was later inserted. This has, at the time of writing, 
been in the nose five months and is obviously permanent. No grafting was attempted on 
the forehead, and the resultant scar is by no means offensive. There is no doubt that, by 
leaving intact the skin of the left ala and columella. the blending of the forehead flap with 



this skin has been rendered very difficult, and one feels that it is better to utilise remaining 
pieces of skin for a lining membrane or to excise them. 

In reviewing this case, one feels the correct procedure would have been a reflection of 
the surface skin over the left ala towards the right, to skin-line that portion of the new nose. 
The flap would have required modification to include the left ala and remains of the tip, 
but the natural form of this nostril would still have been kept intact by the supporting 
structure, and a more homogeneous appearance would have been readily obtained. 

The following are the details of the case : 

At an operation performed on 20.6.10 the left middle turbinate was detached, except 
at anterior end, swung forward on itself, and stitched to the remains of the septum in order 
to build up the bridge of the nose by stages. 

On 9.8.16 the right inferior turbinate bone was removed by detaching it posterially 
as far as its anterior end, and grafted on to the already partly formed turbinate septum, 
i.e. superimposed over the middle turbinate in its new position. 

Under local anaesthetic, the anterior attachment of the right inferior turbinate, which 
was turned up in previous operations, was freed and sutured to the remains of the tip of the 
nose to form a bridge. 

A rhinoplastic (three-quarters total) operation was performed on 11.10.16, when a 
celluloid plate was first placed from the frontal bone to the tip of the nose over the existing 
turbinate bridge and stitched into place. A flap with its base on the internal angle of the 
right eye and extending obliquely upwards to the left temple was cut according to the 
accompanying shape and dimensions vide diagrams. It was twisted down and sewn 
into position. The right ala was formed by curling the tip of this flap over a small celluloid 
piece stitched to the tip at one end and to the cheek at the other. No seriovis attempt 
was made to close the frontal wound. A relaxation suture from the flap to the left cheek 
was inserted. 

On 28 . 10 . 16 the frontal flap was cut through at level of eyebrow and also at attachment 
to left eyebrow region, and the pedicle returned to the forehead. The newly cut portion 

FlGS. 586 and f>87. Indian rhinoplasty over celluloid supports. The lining was provided by turbinate grafts 
at the bridge and the infolding of the end of the frontal flap at the vestibule 



of the flap was fitted in to form the upper part of the bridge of the nose. In joining this 
to the skin above, the nose flap was made to lie underneath the upper skin by cutting both 
very diagonally. Conversely, the skin near the eyes was made to overlap the skin of the 
nose by similar but reverse method. The nose was not entirely closed on the left side, 
and this necessitated a small skin-flap from cheek at a later date. 

The celluloid splint was removed from nose on 29.1.17. 

On 17.4.17 an implantation of homologous cartilage was performed.' Two lateral 
incisions from root of nose up over frontal region were made, flap of periosteum turned 
down, and bone chiselled upwards forming a notch. The skin was separated from under- 
lying tissues over the whole length of dorsum, rib cartilage inserted, and passed through 
a hole in periostea! flap, the upper end of cartilage engaging in notch of bone ; a small 
piece of cartilage to reinforce left ala. A small flap was taken from the left cheek to relieve 
tension when suturing in this region. The bulk of the right side of nose was reduced by 
removing an elliptical piece of skin and drawing the edges together. 

A further operation was performed on 18.9.17 for implantation of autologous cartilage 
into bridge of nose. The cartilage inserted at previous operation lias become entirely 
absorbed and the nose has flattened. The cartilage was inserted from above and went as 
far as the tip. The support of the cartilage was made by splitting it so that it straddled 
the deep tissues. Its length was about If in. An attempt was also made to make an ala 
on the right side. There is still, however, too much tissue on this side. Cartilage taken 
from the seventh right rib. 

A small corrective operation, performed later, brought this rhinoplasty to its present 

Fio. 58S. The turbinate grafts complete, 
forming support and mucous membrane 

Fio. 580. The celluloid strips Imd to be removed 
and this globular appearance resulted. 



FIGS. 590, 591, and 592. After autologous cartilage graft to bridge and trimming of right ala. The forehead 

healed by granulation, the pedicle being returned. 



CASE 132 

The treatment of this case by skin-grafting the intranasal aspect of the new nose 
marks a definite stage in the advancement of rhinoplasty. 

The injury involved complete loss of nose and its supports, together with a large portion 
of the left superior maxilla. The appearance on admission after ten days was that of a 

large crater in the middle of the face which nor- 
mally was filled by the nose. 

When the tissues had become healthy, an opera- 
tion was undertaken to establish and maintain the 
airway ; skin-grafts were applied to the raw areas 
after the intranasal adhesions were freed. This 
proved a satisfactory procedure, and subsequent 
photographs show the complete freedom of the 
right nasal passage from stenosis. 

The restoration of the nose was then designed, 
and a piece of cartilage (the shape of which is well 
seen in the photographs and in the diagrams) was 
inserted through an incision of the scalp near the 
hair-line. This cartilage was taken from the eighth 
right rib and was 3 in. in length ; it was split along 
the lower border and the two halves separated. 
Portions of it were then removed until it took up 
the shape as shown in Professor Tonks's diagram, 
fig. 594. The terminal portion of the cartilage was 
pointed and extended about 1 in. from where the 
new alae joined the tip. This prolongation was for 
the columella support. The cartilage had a ten- 
dency to arch somewhat, and this columella exten- 
sion of the cartilage was causing a little pressure 
necrosis, so that on 30.5.17 the columella was 
divided with a tenotomy knife from its attachment 
to the tip, and a small portion of extruded cartilage at the extremity of the cartilage 
was cut off. The wound then healed without further trouble. 

The next stage of the rhinoplasty consisted in bringing forward, and especially to the 
left, portions of the turbinates and septum, so that there should be a satisfactory bed on 


FIG. 593. Total loss of nose, complicated 
by lateral maxillary and cheek loss. 

A. Portion of inferio- 
Turbinate bone 
swung across. 

Fio. .504. Shape of the cartilage and the position into which it was put. 



FIG. 595. Shows the results of the turbinate and septal grafts 
helping to line and support the nose laterally. 

which to implant the new nose. At this stage a colleague. Major Seccombe Hett, R.A.M.C., 

operated, and a description of the operations is given in the following paragraphs : 

1.9.17. Intranasal operation preparatory to plastic operation for complete new 

nose. The left middle turbinal was detached from its connections posteriorly and swung 

forward, so that its posterior end 
was brought in contact with and 
attached to the anterior end of 
the left inferior turbinal. The 
right inferior turbinal was simi- 
larly treated, and its posterior end 
swung up and attached to the 
root of the nose. The cartila- 
ginous septum was detached from 
the floor of the nose and also from 
the vomer. remaining attached by 
a pedicle at the root of the nose. 
It was rotated and placed laterally, 
so that it bridged across the space 
between the right inferior turbinal 
and the left middle, to both of 
which it was attached by cutgut 
2.10.17. Following last operation there is now a mass of tissue filling up the cavity 

to the left of the middle line. The posterior end of the right middle turbinal was found to 

be firmly attached to the septum. Its anterior attachment was now separated and swung 

downwards to floor of the nose and attached there. The result of these procedures was 

that a very considerable gain was obtained, as is very evident from the photograph, fig. 595, 

which shows well the advance turbinals and septum. 

There still remained a big deficiency of the left maxilla, which one decided to fill up with 

a large cheek-flap. 

Operation (Major Gillies). The skin 

and scar tissue lying beneath the left 

lower lid was turned in towards the nose 

with its skin surface facing backwards ; 

the eyelid was thus freed and a large as- 
cending cheek-flap, which is clearly seen 

in fig. 600, was swung into position. 

Thread sutures were used for the deep 

muscular sutures, a supply of catgut being 

temporarily suspended, and these thread 

sutures gave a little trouble, as they tended 

to work out through the scar. No general 

suppuration, however, occurred. 

At the same operation, one decided to 
cpithelialise the lower half of the nose 
while it was still in situ in the forehead. 
The columella and alse of the nose, with 
imbedded cartilage, were outlined by in- 
cision and raised, and the periosteum 
raised for some distance down the fore- 
head. An impression of this cavity was 
then made in Stent, which was next covered 
by fresh Thiersch graft ; it was reinserted 

FIG. 5!)f>. View from above forehead. Skin-graft on 
the under aspect of the flap and on skull. Photo taken 
on the eleventh day after operation. Note : the graft 
was so perfect that it could be picked up and sutured 
to the skin round the alao. 



and the skin sewn up. A little suppuration occurred, and when the Stent was removed 
on the tenth day, only that portion of the grafting which lay under the columella had 
failed to take ; all the rest had taken in a most remarkable manner, as is evidenced by 
study of fig. 596. The epithelium was so good that it could be picked up with forceps 
and drawn round the new ala- and sewn to the skin. The stitches arc in evidence in the 
figure. It was then hoped to leave the nose for a little while, but, owing to obvious re- 
traction and thickening, it was decided to swing it down at once. The further outlining of the 
rhinoplastic flap was undertaken on 12.12.17, and followed the lines indicated in fig. 597. 

The lower part of the flap had been epithelialised by the inlay ; the bridge part was 
lined by turning in small flaps from over the glabella and left cheek. A portion of the 
cartilage was exposed and excised at the time of this operation, as it was found that 
after the inlay and perhaps even before this stage the cartilage, probably due to pressure, 
had been gradually moving its position and coming nearer the eyebrow. This manoeuvre 
of exposing the imbedded cartilage and excising a portion of it without prejudicing the 
blood supply of the flap, is not a pleasant experience for the surgeon. However, in this 

Fios. 597 and 598. Diagrams of the treatment of the pedicle and forehead deficiency by scalp plastic. 

particular case no infection or loss of blood supply occurred; but, in view of Case 111 and 
others, one is very chary of interfering with the imbedded cartilage until it has been well 
established in its new position. Considerable difficulty occurred in getting the pedicle 
central as is obvious from the photograph, fig. 600. No attempt was made to bend the 
columella which had become very thick and stiff, and it was also found impossible to gel 
the frontal flap to join the skin of the cheek near the left ocular angle. The already thickened 
and swollen nose became larger, but under the influence of electro-therapeutic measures. 
undertaken by Lieut. H. M. Johnston, this nose is assuming reasonable proportions. 

Subsequent treatment consisted in the return of the pedicle on 25.3. 18. The operation 

was performed under novocaine anaesthesia three months later. Also, under local anesthesia. 

various corrective operations were performed to reduce the bulk and remedy small di- 

now became obvious that the Thiersch on the forehead, which had been 

1 on the bone by the Esser-Inlay method, was remaining depressed and fixed firmly 

: bone A plastic operation for its excision was carried out under general anaesthesia 

and the scalp advanced to fill up the gap. 

Details and diagrams of this operation are appended : 

19.7.18. Operation. Under general anaesthesia. Object to remove large depressed 
skill-grafted area on forehead and raise eyebrow, etc. 



FIG. 599. Profile showing the 
cartilage in forehead. 

FIG. 600. The early, very thickened, result. 
Note the skin-graft on forehead. 

FIG. 601. Profile of same stage. 
The columella was so swollen that 
it could not be bent into position. 

FIGS. 602 and 603. Result of the treatment. 



Long incision from right eyebrow to top limit of forehead scar followed by the excision 
of the remains of the skin-graft and sear tissue. The right eyebrow could now be lifted to 
its normal level. In order to get an easy closure of the forehead, an advancing flap from 
the temporal region of the scalp was swung down to complete the forehead. Further 
plastic adjustments at the root of the nose, combined with an excision of part of the imbedded 
cartilage, produced a very much more satisfactory result in the glabellar region. A deep 
catgut suture from the tissue overlying the cartilage to the periosteum of the glabellar 
region gave a hitch to his nose which lifted the tip and columclla into a very satisfactory 
position. It was not expected, however, that the elevation of this would remain so marked 
owing to the attachment of the nose to the left cheek. 

1.8.18. Progress. Satisfactory. Slight dropping of tip noticed. The total result 
to date is sufficiently satisfactory, and is probably capable of much improvement. 

FIGS. 604, COS, and 600. Shortly after final corrective operation. 





THIS section includes not only description of injuries of the orbital ring, of 
the eyelids and the sockets, but, in addition, the operative treatment of burns. 
The most important and outstanding result of severe facial burns is ectropion 
of the eyelids. It was found impracticable to devote a separate chapter to 
burns for this reason. The palliative treatment of paralysis of the eyelid muscles 
and the principles of otoplasty are also discussed. 

For convenience of discussion injuries of the eye region are subdivided 




In a subsection of this chapter Burns of the Face plastic operations 
on the pinna are discussed. 




Many gunshot injuries result in loss of the superciliary ridge of the frontal 
bone, the external angular process, the malar bone, and the infra-orbital plate. 
With these bony losses of the orbital borders are frequently associated losses 
of the lids and damage to the eye and socket ; but in the following cases I have 
limited the examples to those in which the repair is mainly centred in replace- 
ment of the bony contour. These are among the most satisfactory of the 
plastic restorations of the face, and, provided the eye-socket is clean, there is 
little risk of infective troubles. However, when the injury involves the frontal 
sinuses, care must be taken that the graft restoring the shape does not lie in 
connection with the mucous cavity. The restorations have been made mostly 
by the aid of shaped cartilage implantations, and almost perfect restoration 
of contour has thereby been obtained. 

When a larger loss of bone occurs, constituting a cranial defect, the cranial 
cavity may be shut off by an osteoperiosteal graft which I have not personally 
used or by an extension of the cartilage restoration. It is advisable to work 
out, with the aid of the sculptor, the exact amount and shape of the loss, and 
to make a metallic model of the necessary implantation before the operation. 
This enables one to shape the cartilage exactly at the time of operation. 

Frequently it is necessary to replace the eyebrow. The loss of the eyebrow 
hair is a serious defect, which may be corrected by the wearing of artificial 
eyebrows or tattooing of the skin a quite useful camouflage. Surgical repair 
is illustrated by two cases. In one, a whole-thickness free graft from the hairy 
scalp over the mastoid, and, in the other, a pedicle flap carrying hair from the 
scalp region is grafted into position. Care must be exercised to choose a part 
in which the hairs are growing in the right direction. 

For the external angular process cartilage is indicated, while for the loss 
of the malar the author's temporal muscle-flap is very satisfactory in some 
cases, and in others serves as an excellent basis for the addition of a cartilage 
graft. Loss of the orbital plate of the maxilla, resulting in a downward dis- 
placement of the globe and socket, is remedied by cartilaginous implantation, 
sometimes from the rib, and sometimes from the helix or antihelix of the pinna. 



CASE 307 

This sergeant received a shell-wound in the right temporal region, eausing loss of the 
outer portion of the superciliary margin of the frontal bone. The healed condition is repre- 
sented by a depressed scar which includes the lateral portion of the eyebrow. The scar 
was first excised and the level of the eyebrow corrected. A small flap of temporal muscle 
was dissected and laid in the line of the wound to restore the contour. The result was good, 
excepting a distinct depression of contour, which was remedied later by cartilage graft. At 
the same time, a cartilage globe was inserted into the socket to relieve the sunken condition 
of the lids. This cartilage globe operation is described under the subsection on sockets. 

Operation Notes : 

12.7.17. Operation. For the formation of the right superciliary margin and for 
excision of scar. Scar was excised. As a small amount of muco-pus appeared on the lower 
part of the wound it was decided not to graft any cartilage. In order to make contour, 
incision was prolonged downwards towards the temporal region, and flap of muscle was 
outlined and swung upwards from its origin and stitched to the subcutaneous tissue of the 
eyebrow. In order to get the eyebrow into line, it was necessary to put in a relaxation 
suture with plate. Wound edge closed with thread ; drainage provided by silk-worm gut 
at each end. 

27.10.17. Result of previous operation satisfactory. Slight depression of super- 
ciliary ridge. Eye socket sunken. 

27.10.17. Operation. Insertion of cartilage globe and cartilage into eyebrow. 

Cartilage sphere operation as usual. The cartilage being in one ovoid piece. Small 
strip inserted through small incision in right temporal region to complete superciliary ridge. 

Fid. 607. Excision of scar, adjustment of eyebrow, 
and muscle swing to help fill depression. 

Fia. 008. Suture. 



FIG. 609. Healed condition : Outer part of eyebrow raised by soar, and loss of bony prominence. 

Front view. Semi-profile view. 

Fios. 610 and Gil. After excision of scar and cartilage graft. 


CASE 558a 

A severe gunshot injury carried away a large portion of the frontal bone and the eye- 
brow. The eye had been destroyed or removed prior to this patient's admission. In 
addition to the destruction of all the superciliary margin, there was a cranial defect of about 
the size of a florin. The main scar ran along the centre of a depression from the inner edge 
of the ridge to the external angular process, which was also partly destroyed. 

The interest of this restoration centres in an accident which happened to the cartilage 
graft and in the lesson it taught. A very exact estimation of the amount of cartilage to 
restore the contour was first made and the model cut into two pieces, so that it could be 
reproduced from adjacent ribs. The cartilage was shaped satisfactorily and inserted through 
the end of the scar over the external angular process. The rest of the scar and skin was 
elevated by undercutting until it could be stretched forward to contain the cartilage. 

A very perfect restoration was the result. Hasmatoma and infection followed, however, 
and owing to the exposure of the dura mater, it was expedient to remove the cartilage and 
avoid possible risk of meningitis. 

There is no doubt that (1) a preliminary plastic should have been done to reduce the 
scar and to provide more lax healthy skin to nourish the cartilage ; (2) there is always a 
certain amount of danger of haematoma in these undercutting operations done through a 
small incision, and a more open type of operation is better. 

This infection of the cartilage was the first accident. It was decided to boil this care- 
fully shaped graft for five minutes, after which it was inserted subcutancously over the 
abdomen, where the implantation wound healed satisfactorily. A piece of this was retained 
for histological examination. It should be noted that a cartilage globe was inserted at 
the back of the left eye socket, which was entirely satisfactory. 

After due interval a plastic was performed on the forehead for excision of the dense scar 
and for advancement in a downward direction of the forehead and scalp, so that more 
skin was brought into the eyebrow region. This having healed satisfactorily, the original 
shaped cartilage was removed from the abdominal wall, and a bed made for its reinsertion 
into the forehead. It was observed that the cartilage had the same appearance in shape 
as when it had been last seen some nine months previously. 

While the bed was being made for it, the cartilage was laid in a swab on the instrument- 
table, and its second accident then occurred. One of the attendant " scavengers " of the 
theatre zealously removed, with sterile forceps, what was considered to be a dirty swab, 
and the precious cartilage found its way to an unsterile bucket. It seemed probable that 
the cartilage had touched nothing unsterile, hence it was removed from the bucket and, 
without further incident, was inserted in its bed. No further untoward symptoms have 
occurred. There remains the provision of an eyebrow to complete the case. 

Operation notes : 

23.5.18. Operation. Method of treatment. The necessary amount of cartilage to 
restore the contour was accurately gauged on a plaster cast, and a composition model thereof 
made in two sections by Major Dorrance, M.R.C. The two halves were made so that they 
could be reproduced from ordinary rib cartilage. 

(1) Incision made above remains of eyebrow at outer angle and also above depression 
at inner side. From these two incisions the skin was undercut, care being taken not to 
wound the dura mater. This elevation of the skin was tedious. Cartilage was taken from 
right thorax, shaped by Major Dorrance to pattern. These were slipped in through the 
outer incision, producing a perfect restoration of contour. 

(2) A globe of cartilage was inserted through the conjunctiva in the usual manner into 
left socket. 

Result. Hacmatoma occurred in forehead, followed by temperature and pain. Owing 
to the proximity of the dura mater and the continuance of slight temperature the cartilage 
was removed (27th) under general anaesthesia. 

The surface of the cartilage in two or three places was covered with lymph, showing 
early infection, and culture showed presence of streptococci. A small portion of infected 



cartilage for section was "sent to Professor Keith. 
The rest of the cartilage was boiled for five minutes 
and reinserted into abdominal wall. Subsequent 
progress satisfactory. Cartilage remains same size 
and shape to date 1.7.18 no absorption having 
yet occurred. 

9.9.18. The cartilage graft in the abdominal 
wall appears satisfactory and undiminished. 

9.9.18. Operation. It was decided, in order 
to make a good bed for the cartilage, to advance 
the scalp to bring sufficient skin into superciliary 
region. The scar tissue was freely excised in this 
area, and from the inner extremity of this incision 
the knife was carried up over the forehead and scalp 
for a distance of two inches from the hair-line. An 
abrupt " V " was then made to the left, and the 
knife carried down as far as the left temporal 
region. This enabled the whole of the forehead to 
be suitably advanced. Closure resulted in a " Y ' 

Note. The dura mater was not exposed during 
this operation. Primary healing. 

12.1.19. Operation. Under general anaesthesia 
the cartilage in the abdominal wall was removed. 

(It should be noted that the graft appeared 
much the same in shape and character as when it 
had been inserted after boiling on the occasion of 
the second operation. Piece taken for section.) 

A flap was next turned up by long incision extending across the whole area, so 
that free inspection of the bed could be made. Cartilage inserted and skin sewn up. 

24.2.19. Result. Restoration appears quite satisfactory, and no rise of temperature 
occurred. A slight deficiency in the contour is noticeable in the middle of the area. 

Fio. 012. Cast of healed condition, showing 
loss of superciliary margin. 

FIG. 613. After second plastic in which forehead 
skin was advanced to provide a good bed for the 
cartilage graft. 


FIG. 614. Final ; Contour improved. 


CASE 929 

This officer patient shows a very similar injury to the previous case, but the scar is 
well up on the forehead and the eyebrow is intact. A larger cranial defect is present through 
which the pulsating dura mater is plainly visible, and the external angular process has 
also been shot away, together with a portion of the malar region. The socket holds an 
artificial eye, but this eye is turned latcralwards. Another feature about the cranial defect 
is that the depression is very considerably diminished when the brain is under higher pres- 
sure ; the two plaster casts illustrated show this difference in contour, due to differences 
of the intra-eranial pressure. The first stage of the reconstruction has been carried out 
by implantation of cartilage graft from adjacent ribs. The scar on the top of the forehead 
was utilised for the incision of a flap which provided a clear view of the operation area. 
A little more of the external orbital ring remains to be built up by the aid of spare cartilage, 
which was taken at the time. 

27.1.19. Operation. General anaesthesia. Incision over the right rectus and ex- 
posure of the cartilage area. The attached adjacent portions of ribs 7 and 8 were removed 
also a spare piece. Wound closed and spare piece inserted subcutaneously. Two joined 
cartilages were properly shaped. Incision over the left forehead along the line of 
the scar, curved downwards at each end so that full exposure could be obtained. The 
skin was very carefully undercut, so as to avoid wounding the dura mater, which was closely 
adherent. The flap was turned down and all bleeding points stopped. Cartilage inserted, 
and sewn down by cutgut to the periosteum at each end and the wound closed. 

Result. Wounds healed by first intention. 

Complication. Influenza developed third day. 

FIG. 015. On admission. 



FIG. 016. Cast taken while intra-cranial 
pressure was raised. 

FIG. 617. Cast while intra-cranial 
pressure was low. 

FIGS. 618 and 619. After cartilage implantation. 



CASE 75 

In this injury the loss of the bone is considerably loss and there is no cranial defect, 
but the eyebrow lias been destroyed over its outer two-thirds, its place being taken by a 
dense scar which also runs across the external angular process to the cheek. The left eye 
socket, which was carrying an artificial eye, is considerably depressed. 

FIG 620. Temporal flap outlined. 

FIG. 621. Suture. 

The reconstruction of the eyebrow was first 
attempted by use of a flap, which is seen in the 
diagram. It was cut from the left temporal 
region, where the hair grows in the requisite 
direction. Fig. 623 shows the bridge pedicle 
flap in position ; this was not tubed. Uoth 
the flap operation and the return of the pedicle 
were performed under local anaesthesia (infiltra- 
tion Kerocain). 

The further stage of this case will include 
the raising of the socket by cartilaginous im- 
plantation, for which the spare pieces were 

l-'i'i. (>ii. Healed condition (scalp prepared 
tor operation). Outt.- two-thirds left eyebrow 



FIG. 623. Bridge-pedicle temporal flap in position. 

FIG. 624. Pedicle returned. 

FIG. 025. To show minimal disfigurement by 
pedicle scar. 

FIG. 020. After cartilage implant to malar region. 


CASE 518 

This case is unfinished, but is of considerable interest because of the eye socket. The 
original picture, fig. 627, shows that the whole of the malar and a very large portion of the 
upper part of the left superior maxilla have been destroyed. 

The large gap in the cheek contour has been remedied, to a very great extent, by a 
temporal muscle-flap, while the necessary skin has been brought down from the left temple 
region. Although the socket is not yet up to a normal level, a most satisfactory improvement 
has been effected. 

At this officer's own request, his final treatment has been deferred for two or three 
years. It will probably consist in the reconstruction of the nose and the support of the 
left eye socket by cartilage implantation. 

Operation notes : 

21.3.18. Operation. Restoration of remains of nose to normal position. Complete 
separation was made between the remains of the cheek and the nose on the left side. The 
alsc were freed of their attachments and the nose elevated, retained by a head-nose ap- 
paratus (Captain Fry). 

An effort was also made to raise the bridge of the nose by an osteotomy of the right 
nasal process through a separate incision. Nasal passages were partly re-established. 

21.4.18. Progress. Head -gear discarded and lateral spring apparatus fitted (Captain 

20.7.18.- The parts of the nose remaining are in good position, with tip depressed. 

20.7.18. Operation. Plastic on nose, replacement of eyelids, filling in cheek depression. 

Remains of left ala, which was attached to the nose, was divided from above downwards, 
about f in. turned downwards and outwards. Triangular flap, with its base at the margin 
of the nasal fossa approximately 1 in. x l in. was elevated from the cheek and sown 
to the nose to make the inner lining. It consisted of skin with a good many scars. The 
previously detached ala was sutured to the anterior margin of this and to a raw area on 
the upper lip. 

A semicircular incision extending from in. above and to the inner side of the inner 
canthus downwards and outwards on the line of an old scar to a point an inch external to 
the external canthus. 

The upper and lower flaps were elevated, leaving a depressed area approximately 1| in. 
in width. 

The lower eyelid was now sutured to the inner end of the above described incision, in 
this way returning the eyelid to more normal position. 

A skin-flap was now elevated from the left frontal and temporal regions, with its base 
extending forward for 1| in. from the upper margin of the left ear. This flap Avas long 
enough, when reflected, to reach the side of the nose and cover the exposed area below the 
eye. This flap contained the temporal artery. The anterior half of the temporal muscle 
was now elevated from its fossa, the superimposed fascia divided where it was originally 
attached to the zygoma. A tunnel was now established beneath the scar tissue, which 
represented the original position of the zygoma, and the muscle was drawn through this 
tunnel to fill completely the depression under the eye. The temporal muscle was then 
sutured over this muscle to the margin of the skin. The skin margins of the frontal and 
temporal regions were undermined and approximated in the frontal area. The temporal 
area will be filled by return of pedicle. Operative result very satisfactory. 

5.11.18. Operation. Return of pedicle to temporal region (local anaesthetic). 

6.12.18. Operation. Excision of scar, together with a small plastic on the left ala 
in order to improve the airway. 

Patient now wishes to return to civil life. The cartilage to nose and lower eyelid have 
therefore been postponed. Rest of cheek plastics very satisfactory, the very large depression 
having been completely filled. 



FIG. 627. Healed condition : Loss of prominence of infra-orbital margin, 
distortion of nose and stenosis left naris, malposition left lower lid. 

Fio. 628. Infra-orbital depression almost overcome by temporal flap. Xose straightened and 
naris remade. Lower lid replaced. Case unfinished : for cartilage implants later. 



CASE 40 

This case has been illustrated in the section on cheeks, and shows loss of the orbital 
ring through depression of the malar, together with dragging downwards and outwards 
of the outer canthus. It is cured by the author's temporal muscle-flap, for details of 
which see Section on Cheeks, Case 40, p. 54. 

l'ic. (129. Depression in malar region. 

Fia. 630. Depression relieved by temporal muscle swing. 



The following seven cases show more or less severe injuries of the lower 
lid, with loss of the lower lid and traumatic cctropion. 

Where the loss of the lid-edge is one-third or less, a very satisfactory repair 
can be made, but where the whole lid has been destroyed the operation results 
seen by the author are considerably wanting in finish. 

Of the various methods of blepharoplasty used by ophthalmic surgeons 
after tumour removals, however, few seem to have recognised the principle 
of providing all the elements of the lid that is to say, lining membrane, support, 
and skin covering. Mellor (Vienna) uses free transplants of skin and cartilage 
from the ear, which are attached to the back of the external flap. Pro- 
vided the graft takes, this should give an excellent result. Eversbusch has 
used a pedunculated flap, which is previously skin-grafted before being brought 
into position to form part of a lid. But the other standard operations for 
blepharoplasty would not appear to have embodied the principle of providing 
an epithelial lining. The author wishes to point out that he has had little 
experience of reforming lids when a functional eye is present, and the majority 
of the cases under construction arc those in which the eye has been destroyed 
or removed. Consequently, the value or harm of the presence of a skin surface 
towards the cornea cannot be discussed ; but, when the socket is empty, the 
author is strongly of the opinion that all three elements of the lid should be 
embodied in the reconstruction. Just as in rhinoplasty, skin lining, cartilage 
support and skin covering were found to be essential both for preservation 
of form and function. So in the lid the best results are obtained when this 
principle is carried out. The method preferred is that illustrated in the diagrams 
attached, and it is exactly comparable with the author's skin cartilage swing 
which has been so satisfactory with the nose. 

The operation is divided into two stages. In the first stage, cartilage, 
either from the ear or from the ribs, of a suitable length and thickness, is inserted 
beneath a flap extending outwards from the outer canthus. When the cartilage 
has received its new blood supply the combined skin- cartilage flap is raised 
and swung in on a hinge near the canthus. The skin comes to form the lining 
of the new lower .lid and the cartilage is now on its anterior aspect, and the 
lower border of the skin flap is carefully sutured to the remains of the conjunctiva 
to complete the socket. There is now a raw area double the size of the flap, 
and it may be dealt with in the following ways : 

(a) The cheek wound may be closed by approximation and the lid portion 


(b) A descending temporal skin- flap may be swung down to cover both 


(c) An ascending flap may be brought up from the cheek. 

(d) A double pedicle flap may be taken from the upper lid (Tripier) ; or 

(e) The skin may be conveyed to the lid by a tube-pedicle from the neck 

(author's principle). 

When an eyelid repair is carried out at the same time as a rhinoplasty 
an additional piece can be added to the rhinoplastic flap to provide the necessary 
skin for the lid. 

In regard to the skin-grafting methods for lids, no advantage over the 
Thiersch graft would appear to result from the use of Wolfe graft. Where 
there is no other deformity in the neighbourhood of the lid the skin-grafting 
method produces least additional scar. 

Fid. 631. Flap partly outlined. 

Fia. 632. Cartilage being implanted. 



FIG. 033. End of first stage. 

Fra. 634. Cartilage-bearing flap outlined. 

FIG. 635. Lining and support provided. 

FIG. 636. Skin covering by free graft. 


FIG. 637. Skin covering by flap. 

FIG. 638. Suture. 



Tim r rases arc shown in this group to illustrate the attempted replacement 
of distorted eyelids. 

CASE 699A 

Severe injury lias occurred to the left eye socket and region of the frontal sinuses. 
Cranial defect was present, and pulsation could be felt on the inner 1 wall of the left orbit. 

It is difficult to conceive how the upper lid had become adherent at such a low level. 
A considerable portion of the lower lid edge was still present, concealed in a pocket beneath 
the upper lid. 

An incision was made for raising the upper lid, and a flap including the remains of 
the lower lid was swung upwards and inwards from the cheek. Cartilage was taken 
from the right costal region, and imbedded for future use. Some will be used to cure the 
glabellar depression, while further support to the socket and lower lid will be furnished by 
the remainder. Hchind the new lower lid an epithelial inlay (Esser) has been carried out, 
and a picture, fig. 640, shows, in position, the vulcanite retention apparatus to prevent 
the graft from shrinking until the artificial eye is fitted. 

Operation notes : 

10.9. 18. Operation. Incision made from the inner end of left eyebrow to the attached 
inner end of the upper eyelid, so that this could be completely freed and sewn at a higher 
level. The socket was completed by excising adherent scars and swinging a flap to 
lower lid. Cartilage from costal wall was taken to aid in the reconstruction of the various 
depressions and imbedded in abdominal wall. 

Kesult. Satisfactory. Wound healed by first intention. 

Complications. Acute lobar pneumonia. Recovery. 

20.12.18. Epithelial graft to left lower lid. 

l-'l'i. ''''lit. OIL M.lmijMioil. 

Fio. 040. After lid plastic : Vulcanite in socket 
to control Tliiorsch graft lining lower lid. 


CASE 43 


This case has been described under " upper lips," but this patient also had derangement 
of the left upper lid, which was adherent at a level lower than the lower lid. The inner 
canthus was also displaced, downwards and outwards. By means of the Z incision, shown 
on the diagram, fig. 642, the upper lid and the inner canthus were replaced in nearly normal 

FIG. 641. Healed condition 

FIG. 042. Incision. 

FIG. 043. After plastic to lid. 



CASE 318 

The third case shows a more severe injury of the malar and infra-orbital region, which 
resulted in considerable displacement outwards and downwards of the lower lid. 

The main restorative operation consisted of excision of scar, the bringing down of a 
temporal muscle flap, and suture of cheek-flaps over this muscle transplant. 

Tliis procedure reduced the case to one of ectropion. The lid was really more drawn 
away from the socket than everted. A cartilage rod was fitted in subcutaneously along the 
lower lid. It effected a very considerable improvement, both in raising in the lid and in 
approximating the conjunctival surfaces. There was still, however, an imperfect apposition. 

6.9.17. Operation. Loss of superior maxilla, orbital plate, and part of malar and 
lower lid. Large scar had to be excised first. Two cheek-flaps were outlined for the skin 
covering (see fig. 645), shaped temporal flap turned down, and the anterior portion of 
muscle was swung forward over the remains of the malar-bone and sutured under the eye. 
The wound was closed in the usual manner, and a long relaxation suture was passed to the 

The result is not likely to be more than a good basis for further work. 

19.11.17. Condition. Very satisfactory. Ectropion of lower lid which falls away 
from eye. 

19.11.17. Operation. For lower lid. (1) Implantation of small piece of cartilage 
to stiffen lower lid. (2) Small plastic tip of nose. 

Fid. 644. Condition. 

Fia. C45. Excision of scar, outlining of skin flaps, 
and muscle-swing. 




t Sopporf low.r |i4. 

FIG. 040. After first plastic. 

Fia. 047. Cartilage graft to lower lid and small nose 

FIG. 648. Final. 


CASE 603 

Tliis officer is wearing a right artificial eye, and the left lower lid is the seat of a eicatrieial 
ectropion combined with loss of about a quarter of the lid edge. 

In this type of injury it has been found of great value to support the reconstructed lid 
by 'ocal fat-flaps turned up from the neighbouring region. These fat-flaps are sutured, 
if possible, to the periosteum over the neighbouring bones, so as to help to raise the lid. 

In this particular ease, after excision of the scar, deep tissue flaps were raised from 
beneath the margins of the wound and sutured across the area of the depression thus 
one from over the malar bone was swung across towards the inner canthus, while the other, 
from the infra-orbital region, was swung across towards the outer canthus, a deep catgut 
suture fixing them to the periosteum. In addition to the excision of the scar an appropriate 
cut was made to allow an adequate swinging advancement of the flaps. 

In fig. 651, which represents the result some three weeks after operation, it will be 
noted that the lid-edge has a notch and a depression at the line of suture. Neither of these 
deficiencies was present at the time of operation, and it was interesting to note that, after 
an interval of four months, in which massage and movements had been undertaken, that 
both these minor defects have been rectified. The result, therefore, is one which is very 
nearly perfect. It will be observed, however, that the outer canthus has been displaced 
mesially, which is due, of course, to the suture of a lower lid from which a portion was missing. 
In this operation I had the valuable assistance of Lt.-Col. S. H. McKec, C.M.G., C.A.M.C. 

Operation notes : 

22 . 6 . 18 . Operation. Free excision of scar, which was continued up to the conjunctiva. 
It was decided not to cut any flaps on this occasion ; but to support the lid in its new position 
two fat-flaps were raised from the malar and infra-orbital regions and sutured together. 
(Lt.-Col. McKec assisted at this operation.) 

Immediate result very satisfactory. Later, a slight dragging downward, owing to 
some remaining scar-tissue, is occurring. 

!':. 049. Healed condition. 



FIG. 650. Excision of scar and subcutaneous fat swings 

FIG. 651. Final. (Intermediate stage mentioned in 
text is not available.) 



CASE 123 

The inner half, or more, of the lower lid has been destroyed, while the remaining outer 
portion is caught up in a deep depressed scar descending from the socket to the cheek, pro- 
ducing a cicatricial cctropion. There was also loss of the infra-orbital bony support. 

The method of repair was by flaps, of which the outer consisted of the normal remaining 
lid. At the junction of the skin and the mucous membrane, on the inner quadrant of the 
defect, there was a distinct edge, which was utilised to form the new lid margin of the inner 
half. It contained, of course, no eyelashes. The conjunctiva and skin-covering for the new 
lid were thus provided, and the support was obtained by the use of subcutaneous tissue- 
flaps, which were brought up beneath the new lid and sutured to the periosteum in such 
a way as to raise and support the flaps. A secondary defect now existed beneath the new 
lid, and, in order to take off any tension, an advancing flap was made from the cheek. This 
was first held well up in position by deep catgut suture, which took its purchase from the 
periosteum in the inner canthus region. By this careful suturing of the flaps, the subsequent 
retraction was reduced to such small extent that a very satisfactory lid was produced and 
an artificial eye could be worn. A homologous cartilage globe was later inserted behind 
the conjunctiva, to give more prominence to the artificial eye (eight months after the plastic). 
The final photograph, taken a year after the plastic, shows the result of both procedures. 
Both movement and projection of the eye were good. Diagrams of the flaps used in the 
first operation (9.2.17) are shown, fig. 653. The special arrangement of the subcutaneous 
tissue is not, however, illustrated, but the manner in which flap B, C, raises and supports 
flap A is graphically described. Condition eight months later, and second operation notes 
are appended : 

26. 10. 17. Condition. Result of previous operation good. Scars have become almost in- 
visible, but a notch is present in lower eyelid and the eye is not sufficiently mobile or projected. 

26.10.17. For projection and mobility of artificial eye. Homologous cartilage 
globe inserted under cocaine anaesthesia. The conjunctiva was packed with 20 per cent, 
cocaine and horizontal incision made in it. The cartilage globe inserted in two pieces in 
the form of a cup and ball, and the mucous membrane stitched with horsehair. 

Fio. 65?. Healed condition. 



Note. Some pain experienced. 

Result. Owing to not having quite separated the deep tissue sufficiently there was a 
little tension on one stitch, which gave way, and a small piece of cartilage became exposed. 
This is healing. (20.11.17.) 

10.1.18. Artificial eye fitted. 

FIG. G53. Excision of scar and outlining of flaps. 

Fid. 654. Suture. 

O. 053. Immediately after plastic. 

FIG. 656. Final. 

.-{_' I 


TWO MPS of 1 remaining portion* oV 

lw*r lid . Deficiency of pAlpcfer*l 

sbi(t>d from rb cenfre o\- th lid folh'n*nr 

hide where \f% absence should btlrss nofice&b!. 


\ \ 

CASE 356 

This minor injury of the lower 
lid resulted in the loss of the 
middle half of the edge. Its repair 
was carried out in the form of a 
compromise, thus : a small stump 
of the lid -edge at the inner canthus 
was freed by an incision extending 
down the cheek from the inner 
canthus, and another parallel to it, 
starting opposite the free end of 
this remnant. It could then be 
swung across to meet the normal 
lid-edge of the outer remaining 
portion, to which it was sutured. 
The idea of doing this was to 
transfer the deficiency of lid from 
the centre, where it was very 
noticeable and left the globe con- 
siderably uncovered, to the inner 
canthus region in which its loss 
would appear to be of less conse- 
quence. The eye, before and after, 
is illustrated. 

Flo. 657. 

Fio. 658. Healed condition. 

Fio. 659. Defect camouflaged by translation nearer 
inner canthus. 



CASE 511 

A companion case to the previous one is shown here. But in this instance the direction 
of the wound is different, and the inner half of the lid remains while the outer has been 
destroyed. Free excision of scar was carried out as usual. The lid was raised into 
position, and a descending flap from the upper lid brought down with its pedicle at 
the outer canthus. Similarly, a cheek-flap was swung inwards to fill up the gap previously 
occupied by the scar. The subcutaneous tissue was again manipulated to form a support 
of the lid. The result was sufficiently encouraging, as the level of the new socket was good. 
However, as fig. 661 demonstrates, the outer canthus was considerably contracted. An 
Esser inlay was therefore carried out, and the extent of the skin-grafted cavity, prior to 





external Incision. . 

FIG. 600. Healed condition. 

FIG. 661. After first plastic. 

FIG. 662. To indicate epithelial inlay. 

removal of the model, is shown in outline, fig. 662. This grafted area ran externally to 
the existing canthus, so that, in addition to deepening the lower fornix, the canthus should 
be split open to a greater extent. The epithelialisation of the pocket was very satisfactory, 
and an artificial eye was carried comfortably. The last photograph was taken two and a 
half months after the inlay, and shows only a minor effect in contour of the lid. 

FIG. 663. Before canthoplasty. 

FIG. 604 Final. 



CASE 81 

This is a class of case in which satisfactory results have not been obtained in our ex- 

There is ptosis, lymph-oedema, and immobility of the upper lid, whose edge is also 
partly destroyed. The whole of the lower lid, together with a considerable portion of the 
bony ring, ha's been shot away. The fig. 669 of the result is more flattering than was the 
actual appearance, and the procedure is hardly justifiable in the majority of cases, unless 
an operation for ptosis can be satisfactorily added to elevate the upper lid. The lid may 
also be held up by studs on the artificial eye. 

Strange to say, this patient, with a fixed staring eye whose level was considerably 
below its opposite member, expressed himself as being very pleased with the result, and 
would not wear a shade. More especially with the eye than with any other restoration 
of the face, does an inferior result give dissatisfaction to the patient, and as the eye is easily 
covered with a shade that looks well, anything short of a perfect result is frequently wasted. 

The justification for such operation lies in the possibility that the first result may 
be converted into a success at some future date. 

The first two operations were done in conjunction with Captain Williams, the 
ophthalmic specialist, who designed the temporal flap " A " in the diagram. 

29.9.16. Operation. Excision of scar. An attempt was made to form the lower 
lid by sliding and undercutting the mucous membrane of the upper lid and stitching it to 
the freshened edge. 

1.12.16. Operation. An incision was made on the upper border of the eyelid and 
undercut to the depth of \ in. The scar, which radiated from the external angle was ex- 
cised, and a flap 4 in. long from the right temporo-frontal region was cut, its base including 
the temple artery. This was freed and brought down to form the inner surface of the 
lower lid. Two deep blanket sutures were put in to hold the inner border of this flap down 
to the bottom of the socket, and brought out about one inch below the new palpebral margin 
and tied over a piece of gauze, the outer edge of the flap was accurately stitched to the 
split and loosened lower lid, the rest was sewn up accurately with drainage at its outer part. 

Fio. 005. Shortly after wound. 

Fid. 666. Healed condition. 



28.4.17. Result of the operation 1.12.16. Satisfactory in that it held an artificial 
eye, but too much of this eye was exposed. 

28.4.17. Operation. An incision was made along the summit of the skin forming the 
lower lid and carried into the socket near the outer angle. This released a flap of skin with 
its raw surface outwards, which was sutured to the freshened outer angle. Considerable 
gap was thus formed in the lower lid, which was covered in by a free skin-graft from the 
right mastoid region, including a few lines of hair. 

Result. Partially successful. 

Fio. 667. Flap. 

Fio. 668. Suture. 

Fio. 669. Unsatisfactory result. 



CASE 227 

This is shown as it illustrates the condition of lymph-oedema of the lower lid. I have 
not seen one of these persist after excision of the scar has been efficiently carried out. Flap 
is indicated in the outline. 

Fio. 670. Healed condition. 

FIG. 671. Excision of scar and swinging of cheek flap. 

Fio 672. After excision of scar. 



Two cases of this reconstruction are included in this series, and both, to 
all intents and purposes, show losses of the whole upper lids. 

Two minor injuries, with traumatic ectropion of the upper lid, occurred 
in Cases 365 and 517. See pp. 284 and 288. 

No. 365 was treated by flap operation and resuture, while No. 517 was 
treated by the epithelial outlay method, which will be described under " Burns 
of the Lid " in the next section. 

For the total reconstruction of an upper lid in which the conjunctiva is 
united by scar tissue to the eyebrow, an extension of the outlay method is 
suitable. The lid that results is mobile, and in the position of rest covers 
the artificial eyes satisfactorily. It is not long enough to close over the globe 
in normal position the movement upwards by the remains of the levator 
attachment is, however, quite observable. The most serious deficiency of the 
operation is the absence of the eyelashes. The latter defect can, I am sure, 
be diminished by tattooing the lid-edge, or by the use of grease paint. In 
one case a line of hairs from the eyebrow was included in the new lid, but the 
result was not very good. The author has no experience of implantation of 
single hairs to form an eyelash. When the loss of the upper lid involves more 
of the conjunctiva than of the skin the latter tucks itself in beneath the roof of 
the orbit. To form an eyelid from this condition, attempts have often been 
made to undercut the skin from the conjunctival aspect, and to epithelialise 
its back surface after the method of Esser. For this condition the author 
has advised the implantation of auricular cartilage into the skin remains of 
the lid, which is subsequently swung downwards as a combined skin-cartilage 
flap, similar to the author's other skin-cartilage " swings." 

The original skin surface would thereby line the new lid, and a new external 
covering provided by skin -graft would form an efficient covering to prevent 
contraction. The author has not performed this operation, but has advised 
it, and it would seem a reasonable procedure. From the use of a frontal flap 
no movement in the lid could, of course, be hoped for, unless either the levator 
could be attached to it or a muscle strip introduced. 



CASE 634 

The loss of the upper lid due to this injury is sub-total, since a minute portion of the 
lid-edge remains at the inner eanthus. The eyebrow has been partly destroyed and is the 
seat of a large depressed scar. The lower lid is normal, but the outer eanthus is caught 
in scar. 

The method of treatment consisted in the use of an Esser skin-graft for the author's 
outlay operation, described in the section on " Burns." The first graft that was inserted was 
too short, and a second one was added. The deficiency of the eyebrow was corrected by 
a whole-thickness free graft of hairy scalp taken from behind the right ear. The graft was 
successful, and probably about half the hairs continued to live and grow in the right direction. 
The final photograph is taken without any darkening of the new lid-edge ; but the effect 
of the eye was markedly improved when a dark line was drawn along the part where the 
eyelashes should be. Operation notes follow : 

20.3.18. Operation. Epithelial outlay for new upper lid (partial). Excision of scar 
on eyelid and eyebrow. 

2.4.18. Operation. Removal of inlay. 

Result. Partially satisfactory. The amount grafted was too small and showed tendency 
to retract. 

13.5.18. Operation. Further to lengthen eyelid by outlay. Incision made above 
previous graft. Large inlay inserted. 

18.6.18. Operation. Palpebral fissure widened under local anaesthetic. 

20.8.18. Result of last epithelial outlay satisfactory. Lid rather too long. 

20.8.18. Operation. To correct loss of eyebrow hair. Excision of scar in region of 
eyebrow. A free graft of whole-thickness skin from behind the right ear was cut to requisite 
size. Hairs had not been shaved but clipped moderately short, and their direction calculated 
to be correct when grafted into position. The fatty tissue was scraped off the back of this 
free graft. Its length was that of an entire eyebrow, and less than \ in. in breadth. It 
was sewn into position. In order to keep it firmly down and on tension, a stent mould 
was laid over the graft and catgut sutures were passed over this mould from skin to skin 
to retain it in position. 

Stent removed eleventh day. Graft appears satisfactory. 

Fio. 073. Loss of upper lid and middle one-third 
of eyebrow. 

FIG. 074. After epithelial outlay to lid, and whole 
thickness scalp graft to eyebrow. 



CASE 394 

In this case there is absolutely no remnant of the upper lid remaining, and the con- 
junctiva has been drawn up by scar tissue to the eyebrow, which in its turn has been dragged 
down. The lower lid is normal. 

The Esser graft was used by the author's outlay method, a few of the eyebrow hairs 
being included in that portion which was taken down after the graft had been made. A 
photograph of the result was taken six months after the operation. Though by no means 
perfect, it was distinctly gratifying. 

The condition is, obviously, capable of improvement, but the exigencies of the Service 
demanded this officer's return to duty. 

19.12.17. Operation. For formation of upper eyelid. Method: reverse epithelial 
inlay. Incision made through the lower part of the eyebrow to include a few hairs, and 
laterally towards each ocular angle about two millimetres above the muco-cutaneous junction. 
Incision deepened with the knife, which was carried in the soft tissue lying between the 
conjunctiva and the floor of the frontal sinus. Impression of cavity taken in the stent and 
epithelial inlay made in usual manner. Incision closed. 

Eleventh day. Incision under local anaesthetic along original incision. Removal of 
stent two days later. Perfect epithelialisation. 

Complication. Acute tonsillitis. Area of graft removal slightly infected. 

4.1.18. Operation. Insertion of glass shell. Upper lid looks fairly satisfactory. 

22.4.18. Result of previous operation satisfactory except for small central portion, 
which did not take. This prevented the new eyelid from descending in its central part. 

22.4.18. Operation. Plastic upper lid. Excision of diamond-shaped pattern of scar 
tissue caused by failure of graft, which allowed lid on resuture to descend. Scar at inner 
canthus also excised. Note re skin-graft first operation. The graft was very thick and 
has grown hairs all over it. The patient has had a severe septic throat, followed by a septic 
area at the place where the graft was taken. 

Present condition. Very satisfactory. Discharged to duty, 5.6.18. 

Fia. 675. Total loss of upper lid. 

Fid. 676. After epithelial outlay. 



Plastic problems in connection with the empty socket are mainly of two 
varieties. In one very large series of cases common to all war-injury eye clinics, 
there is a deficiency of conjunctiva causing entropion and contracted socket. 
The other class of cases, which is not so confined to war injuries, presents a 
sunken socket, in which the artificial eye sits far back and immobile. In the 
contracted socket a deficiency of lining membrane may be present in either 
the upper or lower cul-de-sac. 

In cases where the lower cul-de-sac is flattened out until it is on a level 
with the lid-edge a flap of mucous membrane attached to the lower lid edge 
may be raised and tucked down perpendicularly below the lid-edge into an 
incision made for it, and held there by mattress sutures coming out of the cheek. 
This procedure is satisfactory for minor cases, but for the severer forms of 
cicatricial contraction the author's practice is to insert the Esser epithelial 
inlay for the details of which see "Principles." 

This is inserted through an incision in the conjunctiva, and carried down 
for a suitable distance behind the lower lid. Great care must be taken to 
distend the skin-grafted cavity by a mould. A shell with a deep edge to 
go into the sulcus may be used as a retentive apparatus. Sometimes the 
epithelialised cavity is maintained by black gutta-percha, which is moulded 
into the shape of the socket and new cul-de-sac : in this may be cut hollows 
for drainage ; but probably the best method far keeping the socket from 
again contracting is to take an accurate impression and have a vulcanite 
model made for insertion. Close co-operation with an expert dental surgeon 
is advisable. 

It is most important that the grafted sulcus be kept fully on the stretch 
for a considerable period after the operation, and at no time must the pros- 
thesis be removed for more than a few minutes. If this rule is followed there 
\\ill come a time, which varied in our experience with different cases, Avhen 
the skin-graft will cease to contract. This may take three or more months, 
and seldom occurs before two months. When, however, the contraction ceases 
the prosthesis may be left out for nights or even days without jeopardising 
the replacement of the apparatus. It is then quite safe to insert the permanent 
artificial eye. 

Another cause of failure in this operation is as follows : 

The skin-graft is cut badly, and is wrapped around the mould without 
sufficient care being taken to have every surface covered. There are thus some 
raw areas in the new pocket which ulcerate and fail to become epithelialised- 


contraction and infection are then liable to supervene. Marked infection of 
the socket is sometimes seen as a result of the insertion of skin-graft, but this 
may be easily controlled by ordinary methods. 

The method of insertion of the Esser inlay has been modified in the practice 
of the Queen's Hospital, Sidcup, by Major C. W. Waldron, C.A.M.C., who first 
introduced one of these inlays through the mucous membrane, as in contra- 
distinction to the described Esser method, in which the inlay is inserted through 
a skin incision. (This was on a lower lip case.) 

There are certain advantages and disadvantages in either method. In- 
sertion from the skin aspect involves a more difficult operation, external scar, 
and, if infection should occur, a fistula. Should the dissection of the 
cavity towards the mucous surface not be carried sufficiently near the con- 
junctiva, a raw area is left when the model is removed from the conjunctival 
aspect, which is liable to contraction. In one case of the author's this shut off 
the epithelial cavity from the socket. On the other hand, infection is much less 
liable to occur, and possible contraction is less to be feared. Incision through 
the conjunctiva has the advantages of easy removal of the model, simplicity 
of performance, and ready application of the retention prosthesis after removal 
of the stent. There is, however, a greater probability of infection, and there 
is a tendency to push scar tissue on one side rather than to excise it. 

The author has not been successful in grafting mucous membrane to form 
culs-de sac, but he agrees with the suggestion made to him by Colonel Sir Wm. 
Lister and Captain Richard Cruise, that in making these epithelial grafts as 
much conjunctiva as possible should be preserved on the free portion of the 
ocular surface of the lid. 


CASES 511 AND 357 

One of the most successful examples of treatment of a contracted socket is Case 511, 
which has been described under " Eyelids." 

In Case 357 there was cicatricial contraction in both the upper and lower fornices, 
and the original Esser Inlay was attempted through both lids by external incision. The 
upper was successful in producing a satisfactory pocket, but the lower failed in that the 
cavity made for the model was too small and not sufficiently near the conjunctiva. In 
addition, scar tissue was left between the model and the floor of the socket. The stent 
was removed on the twelfth day. It was then found necessary to make a considerable 
incision through the conjunctiva before the epithelialiscd cavity was reached. A small 
epithelial external fistula also existed. The operation was a failure as regards the lower 
lid. At a later date this was reoperated, after which an artificial eye could be fitted. The 
appearance, however, was far from satisfactory, as there was ptosis of the lid with cversion 
of the inner ciliary margin. It is quite possible, however, that the artificial eye might 
have been made to look much better by further corrections of the lid-edge and an operation 
for ptosis. Treatment, however, was not continued, as the socket was still suffering from 
a mild chronic infection. The black gutta-percha model which retained the two grafts in 
position is illustrated, showing clearly the holes drilled in it for drainage. 

FIG. 677. Mould in position. 

Fio. 678. Final : Failure as regards lower lid. 

Flo. 079. Mould removed. 

Fio. 080. Another view of mould. 



CASE 614 

The tarsal plate and inner layers of the lower lid have been destroyed. There is no 
remnant of the lower sulcus, and there is also cicatricial contraction and shortage of mucous 
membrane in the inner aspect of the upper cul-de-sac. 

A large epithelial inlay was inserted beneath the lower lid and contracted area of the 
upper. The graft was retained by the large gutta-percha model seen in fig. 682. The shape 
of the model underneath the lower lid is also seen, causing the slight swelling below the socket. 

Perfect epithelialisation occurred. A deep V Y operation was performed on the cheek, 
which had for its object the raising of this newly formed lower cul-de-sac. The result was 
moderately successful. 

Operation notes : 

12.8.18. Incision was made along muco-cutaneous junction of lower lid, and deepened 
f in. by undercutting the skin over the infra-orbital margin. The upper lid was also freed 
from the adhesion, and an impression of the freshly cut area taken in stent and covered 
with Thiersch graft from left arm. Flavine packing to remainder of socket. 

Result. Satisfactory. Graft maintained by prosthesis, which has been worn since 
above operation. 

11.10.18. Operation. A long V incision and Y suture was carried out to raise the 
new lower fornix. Adjustment of upper lid at inner canthus. 

Fio. 681. Loss of lower fornix. 

Fio. 082. Showing prosthesis in position. 

Fio. 683. Prosthesis replaced by artificial eye. 



The disabilities of this condition are obvious. The eye is seldom sufficiently 
prominent, and the upper lid is concave. In addition, a gunshot injury most 
frequently leaves a stump which very poorly imparts movement to the artificial 
eye. Mule's globes sewn in at the time of the removal of the eye have, in cer- 
tain ophthalmic surgeons' hands, produced satisfactory results ; but when the 
socket is healed and sunken, good results may be obtained by implantation of 
cartilage or fat. Fat has been used for some years. In 1915 Carlotti and 
Bailleul, of Paris, described the use of cartilage. Captain J. L. Aymard described 
an independent modification of this method, in 1917. The operation has stood 
the test of time, and has the great natural advantage over the Mule's globe in 
that it is a living tissue implantation and not a foreign body. For primary 
enucleation of the eye this implant has been modified by stitching the muscles 
to the cartilage globe in approximately their anatomical positions (author). 
Two cases only have been done by this method, one of which was a failure, 
owing to infection of the cartilage as a result of an accident in the theatre. The 
next development in the attempt to produce artificial eyes that move well is 
one which has its basis in the Esser method of skin-grafting. Instead of 
inserting a cartilage globe into the orbital tissues between the muscles, it occurred 
to the author to make an epithelialised cavity in the same situation which 
should carry a deep prolongation of the artificial eye. This extension would 
then be gripped by the muscles and movement transmitted to the artificial 
eye. The whole process is in a state of flux, and no definite pronouncement 
can be made. 

Two out of three cases have been brought to a stage in which a permanent 
epithelialised cavity is situated in the centre of the orbit. The development 
of the artificial eye to fit the same is at the present time in the hands of the 
eye-makers ; but the two cases above mentioned now wearing a special glass 
eye designed for this method are amongst the following. 

For the making of an epithelial-lined cavity in the orbit, incision is made 
as for the cartilage operation, and a conveniently sized Mule's globe inserted 
so that the conjunctiva can be re-sewn over it without tension. A very thin 
'Ihicrsch graft is then wrapped around the Mule's globe. When the excess 
of the graft has been snipped of! with the scissors the graft and globe are inserted 
behind the conjunctiva, which is sewn up over it. This mould stays in for a 
varying time. In one case it came out the next day, but in the second case 
the Mule's globe was retained for five days, while in the third the Mule's globe 
did not make its appearance for five weeks, when the determining factor of its 


extrusion appeared to be an infection following the fitting of an artificial eye, 
there being a slight raw area in the conjunctiva apart from the area operated. 
On the extrusion of the Mule's globe, a prosthesis was inserted after an impres- 
sion had been taken by a dental surgeon. In order to keep this prosthesis in 
position an apparatus may be worn (see p. 204). It remains to fit an arti- 
ficial eye which carries, from its posterior surface, a stalk or prolongation at 
the end of which is a blob fitting snugly into the epithelial cavity. Fig. 700 
shows the view of the epithelial cavity that has been produced, and it should 
be noted that these cavities maintain themselves now for several days without 
contraction and without the wearing of any retaining apparatus. In adapting 
the artificial eye to this principle, the author is greatly indebted to Captain W. 
Kelsey Fry, R.A.M.C., M.C., and Captain Gordon Johnson, and many others 
of the dental and medical staffs. 

In regard to the invention of an artificial eye adapted to this operation, 
the author wishes to express his appreciation of the readiness which the artificial 
eye-makers have shown in the experimental stage. Case notes of the two cases 
and illustrations follow. 




CASE 641 

Tin's socket liad a double deficiency that of complete absence of the lower fornix 
combined with a markedly sunken socket. 

A double procedure was outlined : Firstly the filling of the socket by cartilage globe opera- 
tion, and, secondly, an epithelial inlay to the lower lid. The cartilage operation was per- 
formed lirst. as the socket was a very clean one. The stump produced by the cartilage 
implantations is well seen in the figs, as a globular swelling behind the conjunctiva. 

The inlay operation was performed for me by Captain T. Jackson, R.A.M.C. 

Hoth operations were successful, and a clean socket carrying artificial eye, with moder- 
ately good movement, has been obtained. In regard to the cartilage implantation, two 
pieces were taken from the sternal end of the seventh rib, and shaped into a globe and ball, 

FIG. 684. Contracted socket and loss of lower fornix. FIG. 085. After cartilage globe implant. 

which wm- inserted through a horizontal incision in the conjunctiva. Interrupted catgut 
was used lor the suture material. 

A diagram illustrating the method of the cup-and-ball cartilage implantation is shown, 
he author is not convinced that this shape of cartilage gives any better result 
than a simple ovoid or globular form. 

Fl'J. tixii. () admission. 



Case No. 64lA (Lloyd). Cartilage implantation at time of enucleation. 
Muscles stitched to cartilage. The cartilage prosthesis, in two pieces, cup-and- 
ball method, Avas inserted through a horizontal incision at the back of the socket. 
A certain amount of exposure of the cartilage followed this operation, and 
some of the thread sutures which were used to tie the muscles to the cartilage 
came away. The condition very rapidly cleared up without further infection. 
It must be admitted, however, that when the artificial eye was fitted there 
was no appreciable greater movement than would have probably been the case 
had the muscles not been stitched to the socket. The projection of this eye 
is exceptionally good, and until forced movements are undertaken detection 
of the artifice is exceedingly difficult. Dia- 
gram of the operation and picture of the 
result are illustrated : 

In those cases in which a partial enu- 
cleation is indicated it is considered that 
this cartilage implant would give as good a 
cosmetic result as the Mule's globe, with a 
far greater percentage of permanent success. 

Many other examples of cartilage globe 
have already been illustrated, viz. Cases 
292, 220, 517, 307, 558A, in the previous 

FIG. 088. Showing oup-and-ball cartilage eye. 

Fia. 680. Cartilage eye-implant at time of 

FIG. 690. Final. 

.'} 10 


CASE 519 

Wounded, 21.9.17. Admitted, 30.9.17. 

Kye removed. 

14.3.18. Condition. Sunken socket partial. 

14.3.18. Operation. For insertion of glass ball prosthesis with epithelial covering 
through horizontal incision of conjunctiva (as in and instead of cartilage globe operation). 
The epithelium was sewn over the glass globe with fine catgut. Conjunctiva sewn up 
completely with horsehair. 

l'n>ress. At the end of five weeks very satisfactory. A small portion of the globe 
lay exposed at the back of the socket and was lying in its epithelialised bed, and the move- 
ment of an artificial eye fitted thereon was excellent. Three days after this fitting the 
e< instant manipulation had loosened the glass globe, and, with the addition of sepsis, it was 
expelled. During this period a small adhesion had been cut at the inner points. The 
probable immediate reason of the extrusion was : (1) the manner in which the artificial 
eye stuck by suction to the portion of the globe exposed ; and (2) the infection. 

Note. The opinion of Colonel Lister was taken on this and similar procedures, and, 
in his opinion, no glass globe that became exposed would ever be retained permanently. 


Km. 001. Sectional diagram to show insertion of a skin-covered glass ball. 




FIGS. 692, 093, 694, 695, and 696. At various stages. 

FIG. 697. Final. 


CASE 459 

Wounded, 20.9.17. Admitted, 23.9.17. Operation, 11.3.18. 

Section of right eye socket to show insertion into Tenon's capsule of a Mule's globe, 
surrounded by Thierseh graft, skin-surface centripetal. The skin-graft was tightly sewn 
over the glass globe by fine catgut sutures. The conjunctiva was sewn up with interrupted 
horse li;iir. and a shell was placed over this for protection and retention of globe. 

txplanalory o f model 



A- Lye lid. 
B Ocular conjunlivo 
1 C Tenons Co^sule 

D- Epithelial graft sur- 

E - 

Artificial eye 



!U . 

Fio. 698. Diagrams of the operation. 



FIG. G99. On admission. 

FIG. 700. Showing epithelialised socket. 

Fio. 701. Final. 



Another type of plastic operation which the author wishes to bring to 
notice is that for the palliative treatment of paralysis of the orbicularis muscle. 

The conditions complained of with this lesion are pain and lachrymation, 
due to exposure of the cornea, epiphora due to the paralysis of the orbicularis, 

and headache. 

The author's operation is designed primarily to overcome the exposure of 
the globe : the relief of pain and epiphora is bound up in this. There is, in 
addition, an attempt to reproduce the lid action. 

The principle involved is the provision of closure of the palpebral fissure 
by means of the spring support afforded by a delicate lamina of cartilage, 
operating (in the upper lid) against the pull of the levator palpebra?. Success 
depends on the achievement of just so much closure as can be overcome when 
the levator is put into action. 

This type of operation has been done on six occasions. In all, functional 
improvement has been achieved to a greater or lesser extent, and in three the 
cosmetic result has been distinctly indifferent, owing to prominence of the 
cartilage. In one only has the result approached the author's ideal. 

In the first operation, which is graphically described in the diagram 
Fig. 702, a slender strip of cartilage was divided almost throughout its length, 
so that the two portions remained united at one end. It was inserted sub- 
cutancously through a small incision lateral to the outer canthus, so that each 
portion occupied a position subjacent to the lid-edge. The free ends of the 
cartilage were sutured with catgut through another incision just mesial to the 
inner canthus. This caused the flat strips to bow forward coincident with the 
contour of the globe. Fixation of the graft was ensured by suture to the 
periosteum at cither canthus. A difficulty now appeared. Closure had been 
attained, but there had resulted a slight projection forward of the centre of the 
upper lid from the globe. This was assumed to have been caused by excessive 
length in the upper cartilage bow, and a small piece was therefore excised from 
its centre, with the hope that sufficient spring effect would remain to secure 
closure. This hope, unfortunately, was not fulfilled : the break in the con- 
tinuity of the graft allowed the spring effect gradually to wane. 

In the second case it was decided to over-correct the deformity at the 
outset by the provision of a strong spring, which should be weakened later if 

The cartilage lamina was therefore divided so that the two portions remained 
united at both ends. A complete ring was thus formed, which was inserted 


through an incision skirting the whole of the palpcbral fissure. Suture at the 
angles was very difficult, but the appearance at the end of the operation gave 
great promise. The palpebral fissure remained tightly closed for some two or 
three days after the operation, when the levator action began to assert itself, 
the lids commencing to open slightly and to be closed by the spring. 

Then a misfortune occurred, two stitches giving way at one spot, with 
infection from a chronic conjunctival discharge which had been present on 
admission. The continuity of the cartilage ring, however, has persisted. It 
is intended later to weaken the spring by thinning the cartilage laminsc. This 
should improve the cosmetic result, and should diminish the existing prominence 
of the central portion of the lids. 

A simpler method of spring formation was adopted on subsequent occa- 
sions, a T-shaped piece of cartilage being used, with the stem inserted beneath 
the periosteum of the orbital margin, and the cross-piece subjacent to the lid- 
edge. The spring closure thus attained is balanced, in the upper lid, by the 
action of the levator palpebrse. 

Curvature of the cross-piece in conformity with the globe is ensured by 
leaving the perichondrium on the aspect turned toward the globe. The 
author has found that curvature always occurs with the concavity toward 
the perichondrium, and he has utilised this property of grafts in several of his 


CASE 740 

2.12.18. Operation. Cartilage taken from right costal cartilage in usual manner. 
A thin piece was then cut approximately the length of the lids. It was split in its length, 
i \i < pting a small portion across one end. There were thus two rods of the cartilage attached 
at one end, which were inserted through a small incision in the right outer canthus into 
the upper and lower edges respectively. They were brought out at a curved incision over 
the inner canthus, where they were sutured to the periosteum. A small horizontal incision 
\\as made in the upper lid half-way across to facilitate the manipulation. The cartilage 
at the outer canthus, where the two rods were attached, was likewise sewn down to the 

The effect was now to obtain a strong and complete closure of the palpebral fissure. 
However, the upper rod was too long and the lid was not in apposition with the globe. 
Instead of reopening the inner canthus incision, where the fixation of the rods had been 
difficult, a small portion was excised from the middle of the rod of the upper lid. On tying 
the rod together with catgut it was found that too much had been removed, and, had they 
been permanently sutured together, the lower rod would have bowed the lower lid awav 
from the globe. It was therefore left unsutured in the hope that the spring of the cartilage 
would be sufficient to give a partial closure to the fissure. 

Early result. This was apparently accomplished. 

Later result. No improvement. Operation to be re-done. 


Fios. 702, 703, and 704. For description see text. 



SOME of these cases are among the most terrible with which the plastic surgeon 
is confronted. By a counterbalancing fortune many of them are amenable 
to surgical treatment to a remarkable extent. 

Of the cases of facial burns that have come to me for treatment all had 
an involvement of the eyelids. This is frequently the most important element 
of the disfigurement and disability. In other cases, it is the only disability 
remaining, while in the more severe cases the nose is burned to the bone, the 
mouth is contracted, and the whole of the facial skin has been replaced by 
epithelialised scar tissue. 

The main causes for burns, apart from the ordinary household accidents, 
are, in their order of frequency and occurrence, as follows : 

(1) Cordite Burns. These occur in the burning of munition dumps, from 
backfires, or premature bursts, and from magazine or other fire in naval actions. 

The recipient of this class of burn has usually the power to run away from 
the fire, consequently the area of the face burned is not constant. In the more 
severe forms they resemble the airman's burn, except that, there being no 
protecting leather helmet, there is no line of demarcation. Sometimes the 
upper part of the face receives the full brunt, and, in others, the lower part. 
Whether the neck is involved depends on the clothing that is worn at the time 
of the injury ; thus, an ordinary seaman, whose neck is exposed, has this area 
burnt in addition to the face, while a muffler and a tunic will afford much 
protection to the area below the chin. 

In contradistinction to the airman, whose ears are seldom burnt by fire, 
the greater majority of cordite burns present a lesion of the pinna. 

(2) Petrol Burns. These are caused through a plane catching fire in the 
air or in a crash. The unfortunate pilot or observer usually receives ghastly 
burns of the face whilst strapped to his seat. Should he survive, a typical 
airman's burn results, which may be described as being limited by the airman's 
helmet ; and usually one finds a definite area of healthy skin commencing from 
where the helmet protects the face and head. In one case, the burned area 
stopped just below the chin, where the helmet commenced, but farther down 
the neck two kcloidal scars occurred where the buckles of the strap had become 
red-hot. The extraordinary protection which this leather helmet affords the 
airman leads one to hope that some protecting device against such terrible 
calamities may be devised. The airman's ears usually escape destruction, even 
in severe burns. 

(3) Acid Burns. These are usually the result of a factory accident, some 
caustic, such as nitric acid or sulphuric acid, being splashed on. to the face. 


(4) Burns from Flame-throrver.One case, whose origin is a little obscure, 
said to be due to a German flame-thrower, is the only representative of this 
class of injury which has come under the author's care. 

(5) Electric Burns. One case of electric burn has been under the author's 

In regard to treatment, this should be divided into early, intermediate, 
and plastic. 

In the early treatment the War Office No. 7, substitute for ambrine, would 
appear to give as good results as any. Picric and vaseline dressings would not 
appear to give results markedly inferior to paraffin. McLeod recommends the 
use of stcarate of zinc for the avoidance of limpet-like crusts. 

The rationale of all this treatment would appear to be the non-disturbance 
of the granulating area and the protection of the wound from the air. 

There is no question that frequent removal of dressings which adhere to 
the surface is distinctly disadvantageous. 

Early operative treatment is indicated in the form of skin-grafting to the 
eyelids when the sight is in danger, or when, the shock of the burn having passed, 
a definite and clean raw area is presented ; but no experience can be quoted in 
support of this opinion. 

In regard to the intermediate treatment, when the epithelium is regenerated, 
graduated massage is of great value. Insufficient experience prevents a decided 
opinion on the value of electro-therapeutic measures at this stage, but radiant 
lic-at and ionisation may be carefully employed. 

At what stage should plastic operations be commenced ? This is a difficult 
question to answer, as the time appears to vary in different cases. The author 
is not sure that any plastic operation should be commenced until all contraction 
has ceased and the scars are commencing to become white. This is, however, 
apart from any consideration of plastics on the eyelids, which may have to be 
undertaken for the protection of the globe on short notice at any stage of the 

Another consideration which favours delay is the difficulty in the earlier 
stages of deciding how much regeneration of the epithelium is going to occur, 
and consequently how much of the face it is necessary to replace by healthier 

The third, or plastic, stage having arrived, a further consideration must 
be taken into account. Will the scar so materially improve under X-ray or 
radium treatment that eventually operation is only indicated for parts such as 
eyelids, eyebrows, tip of the nose, or angle of the mouth ? The author feels 
that for severer burns the complete replacement of the scar tissue by healthy 


skin gives a better cosmetic result, and that the trend of plastic surgery to-day 
is towards a more radical procedure. Each case, however, must be considered 
by itself, and the general state of the patient, the physical and mental condition, 
must be weighed in the balance. There is no doubt that in one very severe 
burn the author subjected the patient to too great a shock. 


As has been pointed out, the most important and constant factor in the 
facial burn is the cicatricial ectropion of the eyelids. In only one of the following 
cases have the eyelids escaped. 

For this disfiguring disability the author's operation has completely super- 
seded previous procedures. In only two of the series of ectropion have plastic 
flaps been used, in all the others the author's method, based on the Esser skin- 
graft, has been employed. A typical case of ectropion from fire results in 
the destruction of the skin of the eyelid, leaving the tarsal plate and musculature 
intact. In the worst cases the latter are also involved, and the whole of the 
thickness, even of the lid, may be destroyed. In two of our cases the destruction 
went farther and the globe was destroyed. 

The operation for the typical upper eyelid ectropion or epithelial outlay 
is as follows : 

Incision is made just above the ciliary margin, extending right across 
the involved area, usually from canthus to canthus. The lower flap of skin 
is very slightly undermined, to give a free edge. The upper flap is freely under- 
mined superficially to the musculature, until the lid-edge drops over the globe 
and easily reaches the lower lid. A little further undercutting is continued, 
especially laterally. 

Some sterilised dental modelling composition is now moulded into the 
wound and allowed to set. It is reduced to just such a size as to allow skin 
approximation over it. Its shape is usually one that can be compared with 
the scaphoid bone of the carpus, minus its tubercle. 

The anterior surface of the arm is now prepared for skin-graft by thoroughly 
rubbing with aether all over until it is pink, and an evenly cut thin Thiersch 
graft taken of such a size as can be Avrapped round the mould in one piece. 
The skin-graft has to be placed on the mould with its raw surface outwards. 
Excess of graft is cut off with sharp scissors. 

In the process of wrapping the graft round the mould the centre of the 
graft is laid on the back surface, and smoothed out over the borders towards 
the anterior surface. 








FIG. 705. Stages in the epithelial outlay. 

The graft and 
mould arc now taken 
in rat-tooth forceps, 
the skin smoothed out 
over the anterior sur- 
face, and the excess of 

HOLLOW, SHOWING RflW RE ].. m . n f4- f, ,, f n f f 


With another pair of 
rat-tooth forceps the 
grip is changed and 
the first pair of forceps 
removed. While this 
process, which is some- 
what tricky, is being 
carried out, the assis- 
tant should pass two 
horsehair sutures in 
readiness to be tied 
from one skin edge to 
the other. The loops 
of these stitches are 
held out of the way, 
the mould and graft 
are slowly lowered in- 
to position, and the 
sutures tightened be- 
fore the forceps are 
removed. If after one 
suture is tightened, the 
forceps are removed, 
the mould, with its 
graft, is very liable to 
slip out of the wound. 
The further suturing 
of the wound is carried 
out with horsehair, and 
it is the usual practice, 
in passing the needle, 
to pick up the graft, 
so that it is drawn 

UPPIR no LOWER Eoccs or 
incision aurunio own STENT 




between the raw skin edges. The knots are cut short after being securely tied, 
and the wound painted with tincture of benzoin. 

The eyelid now assumes a position of more marked ectropion than prior 
to the operation, and a protective covering to the exposed conjunctiva is 

After Treatment. The eye is kept clean by boric lotions and the wound 
kept free of scabs, the mould being left in position for some ten to twelve days. 
As a rule, by the end of this time part of the mould is already beginning to be 
extruded through the original incision, and its complete removal is carried out 
by following along the incision line with a thin pair of scissors. Care must 
be taken to reopen the incision right to its full limit otherwise the ends will 
be pocketed. The eyelid now drops to below its normal position, and the skin- 
graft is invariably to be found completely successful ; there are only some 
very small raw edges, due to the reopening of the incision, which remain to 
epithelialise. By the manoeuvre of picking up the skin-graft with the needle 
at the time of suture, the amount of this raw edge is very materially diminished. 

The appearance is somewhat bizarre in the first instance, but the great 
hollow produced by the mould rapidly fills and. smooths out. In the upper 
lid no corrective operations are usually necessary, but in the lower lid the lower 
margin of the graft where it joins the cheek is usually very thickened and con- 
spicuous, and it is usually found necessary to excise this ridge under local 
anaesthesia at a later date. 

Common Errors of the Operation. (1) If done before contraction has ceased, 
i.e. too soon after the injury, the continuance of the fibrotic change in the tissues 
beneath the graft will cause a shrinkage of it. 

(2) The area grafted is frequently insufficiently wide. 

(3) If pieces of the dental composition are chipped off by instruments, as 
when the mould is trimmed with a knife instead of being moulded out while 
hot, or when the mould is handled with rat-tooth forceps which are subsequently 
introduced into the wound, little pieces or chips of the composition get into 
the wound, and act as a source of irritation or infection. 

(4) If the graft is not carefully wrapped around the whole of the mould 
some of the latter comes in contact with the raw surface of the wound, and that 
part is found not to be grafted. 

(5) An excess of graft tends towards the formation of epithelial debris, 
and there is more chance of an infective process commencing. Infection, 
however, is very rare. 

The lower lid is treated in the same manner, but the epicanthus condition, 
which is frequently present, requires a separate graft which cannot be buried. 
For this a piece of modelling composition is merely held down by stitches 


retaining the graft in firm apposition, after excision of the scar band causing 
the epieantltus. The results are very nearly perfect as far as the upper eyelid 
is concerned, both aesthetically and functionally. Those of the lower lid are 
equally successful from a functional point of view, but the appearance is not 
so neat as in the case of the upper lid. Where, in addition to the eyelid 
burn, there is a necessity to replace the whole of the skin of the face, the 
author's tube-pedicle chest-flap methods are indicated. 

The principles of this operation arc as follows : 

The area of the face which is to be substituted by chest skin is accurately 
measured and mapped out on the upper part of the chest. To this area are 
designed long neck pedicles usually two and a half to three inches in breadth, 
and left attached at both ends. The first stage consists of raising the 
pedicles and tubing them that is to say, they are lifted free of the neck and 
sewn skin-edge to skin-edge, into a tube. The pedicles may be single or 
double, according to the amount of facial replacement necessary. The raw 
area of the neck from which the pedicles have been lifted is usually covered 
in by approximation of the skin edges beneath the tube. 

The second stage consists in raising the flap of skin with its pedicle or 
pedicles. After the excision of the burned area of the face the flap is passed 
up over the chin and sutured into the raw area, the necessary cuts being made 
in it for mouth, nose, or eyelid apertures. As a result of experience, it is 
found better to include part of the flap in the tubing, and, after healing 
has occurred, following the second stage, the pedicle is cut from its original 
blood supply, reopened, and spread over the remaining portion of the face. 
For example, it is possible to make the nose portion of the replacement 
with an extra portion of the tube pedicle. 

No pronouncement can be made as to the length and breadth of the pedicle, 
or the size of the flap that can be utilised with success ; but in a patient already 
severely shocked the raw area on the chest is an additional strain, and in one 
case of the author's, where the flap went gangrenous on the face, the double 
raw areas on the face and chest were so severe that the patient succumbed 
three weeks after operation. Perhaps also the mental effect of the failure 
contributed to the poor fellow's demise. In a later case of an airman's burn, 
the procedure has been modified by the introduction of a new principle that 
of shifting the upper end of the tube pedicle first. The various steps in these 
large laeial replacements are reviewed on page 372. The illustrative cases are 
arranged roughly in chronological order as they presented themselves for treat- 
ment. This is done to indicate the process of the evolution of the treatment to 
the present, dat e. :i nd i t. is felt that if they had been presented according to their type 
of injury misunderstanding of certain of the failures might possibly eventuate. 



FIGS. 706 and 707. Before treatment : showing ectropion and epicanthus condition. 


FIG. 708. Immediately after removal of stents. 

Illustrative cases : 

CASE 645 

A burn as a result of this officer's machine 
catching fire in action. Although the whole 
face has been burnt the skin has regenerated 
sufficiently satisfactorily, but gives one the im- 
pression of a face that has suffered from small- 
pox. The eyelids, however, were the seat of 
ectropion, complicated by much scar tissue in 
the inner canthus region, simulating epicanthus. 

Skin-grafts by the " outlay " method were 
applied to all four lids at the same operation, and 
the closure obtained therefrom is well seen in the 
photograph taken immediately after the removal 
of the moulds. Later, it will be observed that the 
epicanthus is well marked on the left side espe- 
cially ; this was dealt with by further skin-graft, 
held in position by stent in the inner canthus 
region ; that on the right was treated by ex- 
cision, which, in this case, appeared to be 

In regard to the cure of epicanthus by this 
skin-grafting method where this is combined with 
a lower lid ectropion, I think it is the best pro- 
cedure to carry the graft of the lower lid round 
the canthus to the upper lid. 


Fia. 709. Same stage later ; epicanthus still present. 

FiQ. 710. After further graft to cure epicanthus. 
Eyes closed. 


CASE 124 

The causative agent of this burn, resulting in ectropkm of the upper and lower lids, 

Milplmrir acid, which reached the eyelids after the bursting of a bottle containing it 
in a munition factory. 

The method of treatment adopted was that of plastic flaps, and three operations were 
required before a sufficiently satisfactory result was obtained. 

The first operation, as illustrated in the diagram, is somewhat wrong in principle as 
far as the upper lid is concerned, as the gain of tissue and resuture of flaps was not sufficiently 
definite. Similarly, the "V Y " operation at this first stage was insufficient to cure the 
lower lid condition. Fig. 712 represents the loss of tissue in the upper lid, combined with 
marked ectropion of the lower. All^the eyebrow had been destroyed, while the next fig., 713, 
shows the result of the first "operation. 

Following this operation a similar flap was let in beneath the lower lid from the cheek, 
with further, but still inadequate, improvement. This was done by my colleague, Captain 

A month later the lower lid was further improved by a swinging flap, as illustrated in 
the diagram. 

The total result was quite satisfactory, but in view of the later results, a quicker and 
better result would have been obtained by the " epithelial outlay " method. 

To complete this case an eyebrow should be grafted into position. A pencilled-in 
eyebrow is illustrated. 

Fio. 71 1.- Diagrams of the three operations (see text). 



Fio. 712. Healed condition. 

Fio. 713. After first plastic. 

Fio. 714. After second plastic. 

Fio. 715. After third plastic. (The left eyebrow 
is pencilled.) 


CASE 338 ' 

This poor sailor was rendered hideously repulsive and well-nigh incapacitated by terrible 
burns received in the battle of Jutland. 

How a man can survive such an appalling burn is difficult to imagine, until one has 
met one of these survivors from fire, and realised the unquenchable optimism which carries 
them through almost anything. 

In addition to the total facial burn viz. destruction of the nose, lips, eyelids (not the 
lid-edges) the ears and neck were burnt ; and the hands were contracted into frightful 


I had only seen one case comparable with this, and that had not yet come to the plastic 
stage ; and it required very considerable moral courage to attempt an operation such as 
could in any way radically cure the condition. 

The process of thought on the problem led one to decide on a double-pcdiclcd chest- 
flap, the pedicles to be tubed to prevent their being infected or exposed, to leave attached 
to these pedicles as large a chest-flap as was deemed viable, and then to place this large 
flap on to the face, excising the area covered by it. 

It was hoped to swing the pedicles, at a second stage, up to the eye region for the cure 
of the ectropion ; but, as will be seen by the progress of the case, a much better eyelid 
operation was, in the meantime, evolved (see Case 152), and this left the pedicles available 
for other purposes. 

The big flap was split at the first operation, to encircle the mouth, the lower border 
of this incision was sutured to the mucous membrane of the lower lip, while the upper border 
was carried round over the tip of the nose ; but the upper lip was not replaced, as the scar 
tissue was not so marked there. In order to get the flap free from tension, it was necessary 
to keep the neck flexed, and an apparatus, in plaster, was fixed behind the patient's head, 
so that this position might be kept. 

The result was very satisfactory in every way, except in that portion of the flap which 
went over the sharp bridge of the nose : at this spot the skin was at its greatest tension, 
and any movement of the head and neck tended to tear the stitches which retained the flap 
on the nose. It was soon found that this small part of the flap began to slide down off the 
nose, and this movement affected its blood supply and gangrene supervened. No other un- 
toward result occurred. 

In regard to the raw area of the chest no attempt at a closure was made, and the main 
line of treatment carried out for this area was the use of paraffin No. 7. At one stage hot 
fomentations were also applied to clean the surface. 

No grafting from the patient was attempted, but three small grafts from another case 
were laid on the granulations, without success. 

The next stage consisted in the severance of the left pedicle ; this was done, under 
novocaine, thirteen days after the operation. The right pedicle was severed about a fortnight 

Three months' rest was given, and then the condition was as shown in the illustration. 
Attached to the cheek on each side were two loose tubed pedicles of skin, and they 
w< -re available for parts other than the eyelids, owing to the development, in the meantime, 
of the " outlay " method. Therefore, at this operation, the left pedicle was partly detached 
from below until it was swung round to form a flap of skin sufficient for rhinoplasty, the 
necessary lining being provided by turning some of the epithclialised scar tissue inwards. 
At the same operation both upper eyelids were treated by epithelial " outlays " in the 
manner described at the commencement of this section. 

Three months later epithelial " outlays " were applied to both lower lids, the secondary 

pedicle of the rhinoplasty divided and trimmed, and the right original pedicle opened out 

and spread over the right cheek, where it was sewn after the necessary excision of sear tissue. 

A long rest was then given to the face, but in the interval an operation was performed 

on the hand. 

Four months after the last face operation, cartilage from another man was inserted 



FIG. 716. Healed condition. 

FIG. 717. Flap swung to face. 

- % 

*^5r *^ 

FIG. 718. Left pedicle divided. 

FIG. 719. Both pedicles divided. 



Fio. 720. Left pedicle swung up to new 
attachment near nose. 

Fio. 721. Lower end of pedicle 
used in remaking of nose. 

FIG. 722. After epithelial outlay to upper lids and rhinoplasty. 
Not* lymph-oedema of nose at this stage. 


Before treatment. Right eye. Before treatment. Left eye. 

Flos. 723 and 724. Showing condition of ectropion. 

into the bridge of the 
nose to give more defini- 
tion and prominence, 
while trimming and al- 
terations were made in 
the right ala. At the 
same operation two 
whole-thickness grafts 
from the scalp were taken 
to make eyebrows. The 
author has found that a 
free graft from the edge 
of the hairy scalp above 
and behind the ear gives 
a satisfactory direction of 
hairs for an eyebrow 
graft. These grafts took 

Operation notes : 

Injury, May 1916. 

3.10.17. Operation. 
Masonic-collar flap with 
double-tubed pedicles 
raised from the chest and 
grafted on to the face 
(author's method). See 

16. 10. 17. Left 
pedicle divided (novo- 

1 . 11 . 17. Right 
pedicle divided. 

19.2.18. (1) Left 
pedicle undercut and 
switched to nose. (2) 
Epithelial " outlay ' to 
both upper eyelids for 
ectropion, by author's 

30 . 5 . 18. (1) Epi- 
thelial " outlay " to both 
lower lids. (2) Trimming 
of nose pedicle. (3) The 
original right pedicle 
spread across the right 
cheek towards the ear. 

6.3.19. (1) Carti- 
lage (homologous) to 
nose. (2) Trimming of 
right ala. (3) Whole- 
thickness (Wolfe) grofts 
from scaly to form eye- 


Right eye open. Left eye open. 

FIG. 725. Right eye soon after graft. 
The edges of graft are too abrupt. 

Closed. Closed. 

FIGS. 726, 727, 728, and 729. After excision of edges of grafts. 

FIGS. 730 and 731. Present condition. Note the eyebrows (free grafts). 


CASE 864 

This naval warrant officer was very severely burned in the battle of Jutland. 

A most interesting record was presented to me by the patient in the form of a photograph 

taken of his face soon after the injury. From this the whole face would appear to have 

been charred, and it is indeed remarkable to note the wonderful progress that had been 

obtained during the healing process. Of what treatment he received, and by whom, the 

author is ignorant The condition on admission is shown in the second and third pictures. 

A very marked cicatricial ectropion of all four lids was the most disfiguring feature of 

the case. In addition, the upper part of the face, from the level of the nose to the forehead, 

was a mass of white, waxy-looking scar tissue. This waxy appearance tended to accentuate 

the glaring redness of the ectropion. 

It was decided to carry out a complete replacement of the upper half of the face, 
and for that purpose a chest-flap, with double pedicles, was designed. 

In order to avoid gangrene trouble in the flap, it was thought advisable to tube the 
pedicles and partly undermine the flap as a preliminary stage, in contradistinction to the 
previous case, in which the pedicles were tubed at the time of operation. As the flap had 
to be carried on to the upper part of the face the base of the pedicle had to be designed at 
a higher level on the neck, and it was in consequence not very broad, being only about 
2j inches. 

An undoubted mistake was made at this first stage in that an attempt was made to 
stretch the part of the flap which was going to fit over the prominence of the nose. Thus, 
the central portion of the flap proper was undermined, and a piece of stent (modelling 
composition) was moulded into the form of the nose on its anterior aspect, and to fit the 
chest on its posterior. 

On this back surface Thiersch grafts were laid, so that the raw area, caused by the 
elevation of the flap, might be partly covered in by epithelium. No skin-graft was laid 
over the anterior aspect of the mould, and consequently infection and irritation of the 
under surface of the flap followed. 

It thus happened that when the flap was raised finally from the chest and sown into 
the appropriate area of the face a very marked infection of the whole area occurred, and 
this, obviously, was entirely due to the attempt above described to stretch the flap prior 
to it being put on the face. This chest-flap was incised in two places on each side, one slit 
for the palpebral fissure and another through which the remnants of the eyebrows were 
brought. The flap, with its double pedicle, in the suppurating stage, is well illustrated 
by the photograph, as are the small areas of the flap which failed to live. 

After the return of the pedicles to the neck, which process healed by first intention, 
considerable time was allowed to elapse before further treatment was undertaken, but 
during the interim massage was administered. 

It is a very interesting fact that this patient could be made to blush into his new flap 
at the time when the pedicles had been just returned to the neck. Since then, not only 
has the power of blushing continued, but the natural lines of the face became at a very 
early date evident, and an accuracy of sensation has fully developed. 

Corrective operations, for enlarging the palpebral fissure and for excision of excess 
tissue, were subsequently done ; but it became apparent that the flap, as grafted, had not 
entirely cured the ectropion. 

Hy this time the author's "epithelial outlay" operation had been fully established, 

kin-grafts in the areas indicated in the diagram were successfully carried out. 
\N ith the addition of artificial eyebrows a presentable appearance was obtained, while 
the ectropion was cured. 

The latest news from this patient, who has returned to duty, is that he has been passed 
by the naval authorities medically fit for service. 



Fio. 732. Soon after facial burn. 

Flo. 733. On admission. Marked ectropion, and 
scarring of forehead. 

Operation notes of this case : 

12.11.17. Condition. Severe cordite burns, face now healed, affecting mostly upper 
part of the face. Loss of both lower lids. Loss of both upper lids, with marked ectropion. 
Remains of the edge of the lids, and some eyelashes, are present. Forehead and eyebrows 
burnt and scarred. Slight remnant of each eyebrow remains. Nose, fleshy part, burnt 
off, and a thin white ivory scar remains. A similar white scarring below and external to 
each eye. 

12.11.17. Operation. Chest-flap, fig. 734. 

Note. Central dotted portion was the area raised by the stent mould, the under 
surface of which carried skin-graft for the chest- wall. 

18.11.17. The stent holding in the graft caused trouble, too much tension over 
the tip of nose, stitches had to be cut, collection of pus, and temperature until removal of 

30.11.17. Operation (second stage). Transference of flap to face after excision of all 
the epithelialised scar tissue, from the level of the tip of the nose to \ in. above the eyebrows. 
The blood supply of this flap was noted to be fairly satisfactory at the operation. 

13.12.17. Progress. Very considerable suppuration followed operation. The flap 
was almost floating in pus at one time, and drainage tubes had been inserted at several 
places. Small area of gangrene occurred over the tip of the nose and above the eyebrows. 

8.1.18. Operation (third stage). Pedicles returned to the neck. A free blush into the 
new flap is to be observed. 

9.5.18. Operation. Palpebral fissures widened. Excision of scar tissue at margin 
of flap. 

24.7.18. Operation. Three epithelial "outlays." See diagram. 



FIGS. 734 and 735. To show tubing of pedicles and undercutting of flap. 

Fio. 736. Flap in suppurating stage (see text). 

737. Pedicles returned. Ectropion persisting. 



FIG. 738. Showing areas treated by outlay. 

FIG. 739. On discharge. Ectropion relieved. 


CASE 388 

There was a very pathetic sequel to this most terrible case, in that the patient after 
having survived the ordeal of the burn, lived and regained a certain amount of strength 
twi-nty months after the injury, died as a late result of a plastic operation. 

He was admitted to my care fifteen months after the injury. The picture of the con- 
dition shows the injury remarkably well. The colour of the scar tissue, which was an ugly 
red made the appearance more ghastly than the illustration portrays. In addition to the 
left eye being burned and to all the other destruction in evidence, the right eye was prac- 
ticallv blind, as a result of staphyloma of the cornea. 

He had received most painstaking and careful treatment prior to his admission to my 
department ; included amongst other things, a skin-graft to the upper lid had been done, 
which undoubtedly saved the remaining sight. 

In view of the success of the two cases of burns described before this one, it was decided 
to replace the whole skin of the face by a chest-flap. The flap was designed larger than 
those for the two previous cases, and was of sufficient size to cover the whole face. As a 
preliminary, the neck pedicles were tubed. At this stage also incisions were made into the 
area of ski'n which was going to form the face, and they represented the slits necessary to 
make the mouth, nostrils, and palpebral fissures. These incisions are distinguishable as 
scars in the illustration, fig. 742, and it should be noted that they became keloidal scars and 
did not heal up at all quickly ; they were sewn up with horsehair. 

After the pedicles had been made, a rest of two and a half months was given, as the 
patient was obviously slow in recovery, both generally and locally, after which it had to be 
decided whether to give this unfortunate airman a further year's rest or whether to carry 
on with the procedure, knowing that the latter might not succeed. 

The patient had got used to a considerable amount of morphia and a certain amount 
of stimulants since the time of injury, which was certainly derogatory as far as his treatment 
was concerned. Having pinned his faith on the result of the forthcoming operation, he 
was bitterly disappointed and exceedingly depressed at the thought of having to wait another 
long period, and it was feared that he would not wait so long. 

Owing to the generally poor healing powers of the patient, it was decided to add two 
more pedicles to the flap, the design of which is visible in the illustrations. The operation 
was duly carried out, and was an exceedingly tedious one. Skin to cover the raw area of 
the chest was taken from a volunteer, which part of the operation was very kindly 
undertaken for me by Lieutenant-Colonel H. S. Newland, D.S.O., A.A.M.C. 

The appearance at the end of the operation was pleasing, and the blood supply to the 
flap seemed sufficient to ensure its persistence. When the patient had recovered from the 
shock of the operation and the long ana>sthetic there was, quite obviously, good blood 
supply in the flap. Next day, however, the patient was considerably collapsed, and the 
flap itself suffered in the general depression of circulation, and in thirty-six hours became 
blue. From then onwards there was a steady progress of the gangrene, which went from 
dry to moist over all the flap, except a small portion of each pedicle. The skin-graft to 
the chest failed to take, and despite the most unremitting care of the sister in charge, and 
Captain R. Montgomery, R.A.M.C., the patient gradually sank and died twenty-four days 
after the operation. Both the chest area and that of the denuded face became infected, 
and towards the end mctastatic abscesses occurred in various regions. 

In reviewing the case, the attempt to reconstruct the whole face is a procedure which 
is obviously justifiable, and it would, in a more reposed patient, have succeeded. It 
is possible that, had the author taken a very firm attitude, and could he have persuaded 
the patient to wait a year, the operation, as planned, would have had more chance of success. 
The author is convinced that the operation should have been done in piecemeal perhaps 
that one <|n;irtrr only of the face should have been done at a time. By this means a very 
presentable result mi^ht have been gained ; but it obviously would not have been as good 
as the single replacement method, and the author feels that his desire to obtain a perfect 
result somewhat over-rode his surgical judgment of the general condition of the patient. 



The operation took much longer than was anticipated, the shock was greater, and with the 
failure of the skin to take on the chest and of the flap to live on the face, the severity of 
the operation was enormously increased. One could have wished that this brave fellow 
had had a happier death. 

Fid. 740. Healed condition. 

FIG. 741. First pair of pedicles tubed. 

FIG. 742. Flap and second pair of pedicles out- 
lined. Note keloidal condition of scars. 

FIG. 743. Flap swung to face. (See text.) 



CASE 152 

This gunner received, on 22.10.16, a cordite burn, and was admitted three months 
later, when the condition was still unhealed. 

After another two months, the first plastic was performed, and this consisted in the 
excision of scar tissue across the root of the nose anil the left inner canthus region ; the 
raw area thereby caused being filled in by two flaps. The main one was brought down 
from the forehead and laid across the root of the nose and left inner canthus region : the 
subsidiary flap on the right side was made to advance to complete the right aspect of the 

The result of this operation was unsatisfactory, as an acute infection was lit up by 
the excision of the scar and no primary union occurred. 

Next, a whole-thickness free graft (Wolfe) was attempted in the right lower lid, below 
the eanthus ; but there was no definite evidence that any benefit had accrued. 

Before the next stage the author had been doing the Esser inlay for entropic conditions, 
and it occurred to him that the process might be reversed and the principle applied to ectropic 
conditions. To distinguish the latter from the Esser inlay the name " epithelial outlay " 
was given it ; and the operation is described on p. 350. 

As regards the upper lid, the result was all that could be wished, but a certain amount 
of infection of the lower left lid occurred, and the area grafted has not blended with the 
surrounding tissues. 

Operation notes : 

Operation. Excision of scar and flap operation as per diagram. 

4.6.17. Operation. For restoration of right lower eyelid. Excision of scar and 
replacement of lid to normal level. A triangular piece of skin from the chest, denuded of 
fat (size, roughly, f in. each side), was inserted and stitched in. 

23.11.17. Result of free graft was problematical. Slight ectropion of lid. 

General condition. Great improvement in skin under massage, still ectropion of lower 
lids and marked 'shortening of left upper lid. 

23.11.17. Operation. -To cure ectropion condition all three lids by reverse epithelial 
inlay method, or epithelial outlay. 

1. Incision over left upper lid widened and deepened, until lid dropped into position. 
Cavity deepened further, and an impression of this cavity taken in stent, covered with 
Thiersch graft, and sewn up. 

2 and 3. Similar procedure in both lower lids inner ocular angles. External in- 
cision reopened and stent removed. 
This allowed the upper lid to fall 
down into position. 

Later : The left lower lid stent 
was extruded and a little suppur- 
ation occurred. The right side was 
taken out on tenth day. 



Fio. 744. Excision of scar and plastic 

Fio. 745. AVolfe graft to relieve ectropion right 
lower lid. 


Fio. 746. On admission. 

FIG. 747. After first plastic. 

FIG 748. After outlays. 

FIG. 749. Final : Showing relief of ectropion. 


CASE 513 

This is an excellent example of the use of the tube-pedicle flap to replace a portion of 
the face. 

The burn, on this occasion, was due to the premature burst of a shell in action. 

Apart from the eyelids, which were the seat of cicatricial ectropion, the whole face 
and neck were generally burnt, but had recovered with slight disfigurement of the skin, 
except in the region along the line of the mandible ; here was marked, dense, keloidal scar 
extending from one ear to the other along the mandibular contour, considerably more 
marked on the left. 

The first and most important part of the treatment consisted in providing the cornea 
with a covering, and, in order to cure the ectropion, epithelial outlays were carried out for 
both upper lids. At the same time the right mandibular scar was excised, and the skin 
merely approximated. 

The early results of the epithelial graft of the eyelids were satisfactory, but a certain 
amount of contraction subsequently occurred, not sufficient, however, to cause discomfort 
to the patient. 

At the next stage, undertaken five months later, a flap was designed on the left side 
with the base in the posterior triangle of the neck. Parallel cuts were carried downwards 
ami inwards over the anterior chest wall, separated by an interval of 3| inches, the width 
of the flap. 

The flap was raised and sewn into a tube in the usual manner, by sewing skin edge 
to edge on its under surface. The area from which the flap was raised was covered in by 
widely undercutting the skin margin and approximating them beneath the tube. The 
result was satisfactory. 

It is to be noted that in order to get the closure more easily, the skin over the posterior 
triangle was advanced up to the clavicle and held there by deep catgut sutures passed 
through the periosteum of that bone. Twenty-one days later the lower end of the flap 
was detached, partially opened, and grafted into the chin area. The necessary amount of 
scar tissue was excised to receive it. 

Two months afterwards the upper end of the tube flap was detached, the rest of the 
scar tissue extending up to the ear was excised, the tube opened, and the flap spread across 
the raw area. The upper extremity of the flap was split, one portion going over the front 
of the ear and one behind. This was done in order to free the pinna, which was involved 
in the general scar contraction. It should be noted that the blood supply to this flap was 
perfectly satisfactory, both at the first and second shifts, but of the two the second shift 
appeared more safe than the first. If this indication is true, it would indicate that the 
new blood supply to the flap from the chin region was of a more vigorous nature than that 
which it received from its original base in the neck. As a corollary, if this hypothesis is 
true, the radical procedure of shifting the base of the pedicle first would be indicated. This 
has, in a later ease of the author's, been undertaken, but there are not sufficient data to 
establish the principle. 

Great relief lias been experienced by this patient in the additional freedom of movement 
by the excision of the scar. 

*._'. is. ()/iiriiti<m. Epithelial outlays, both upper eyelids for ectropion and excision 
of riylit mandibular scar extending up as'far as the tip. 

AY.s ult. Almost, complete closure of palpebral fissure. Some subsequent retraction 
liiis occurred, caused by amount of scar tissue present. 
1 s . .' . 1 8 . O/in-dtion. Removal of stcnt. 

25.7. 18. ()/>, ml ion. A flap was prepared from left side of neck and left pectoral region 

for transference tot he mandibular region to replace scar tissue. Width of flap 3| in., parallel 

ut, the outer cut emitiimcd farther down the chest than the inner base of flap, in posterior 

triangle of left neck at the anterior border of the trapezius. After undercutting this flap 

it was \, is can fully tubed. 




.r : ii m / j.m 

k. ^^^^^^^^^^^^ ' J^^H 

?V -~a / 

Fios. 750 and 751. On admission. 

Fio. 752. Showing area excised and preparation of tube pedicle. 




Hy extensive undercutting of the remaining skin and suitable advancements, it was 
found possible to get a complete closure under the pedicle. (Note that a special advance- 
ment of the upper end to the clavicle helped this considerably.) First of all a number of 
deep relaxation catgut sutures were inserted. Two of these united the trapezius and sterno- 
mastoid muscle to the periosteum of the clavicle to obliterate the usual supra-clavicular 
hollow. Relaxation sutures and buttons were also used. Drainage tube from clavicle 
region. Result satisfactory. Primary union. 

3.8.18. To transplant the pedicle flap to take the place of the scar tissue on neck 
and chin. The scars on neck and chin were excised, as shown in photograph. The 
skin retracted about 1 in. The portion of skin marked " A " was retained, freed, and 
swung to the left with its base attached upwards. The pedicle of the tube-flap was separ- 
ated at its extremity, and its outer half opened up and sutured to the raw area made by 
the excision of the scar. At the inner canthus of each eye a small plastic was performed 
to correct the tendency to almond eyes. 

Fio. 753. Pedicle tubed. 

Fio. 754. Chest-flap swung to chin. 



Side view. 

Front view. 
Fios. 755 and 756. After plastic. 


CASE 1002 

Case 1002 was almost a typical " airman's burn "that is to say, serious damage 
is limited by the airman's helmet to the face ; the upper half of forehead, and the ears and 
neighbouring strip of cheek escape. There was, in addition, a less serious bum of the 
fronto-parietal region. 

The resulting keloidal scar had led to severe ectropion, distortion of alse ot the nose, 
and microstoma, barely admitting a teaspoon. 

Attempts had been made elsewhere to skin-graft portions of the face, and the appearance 
on admission is shown in fig. 757 (22.8.18). 

With a view to softening the scar and improving its blood supply, a thorough course 
of X-ray and diathermic treatment was undertaken. This led to a definite improvement, 
and by "27. 3. 19 the prospect of operation appeared favourable. 

This case is important, as being the first in which a postauricular flap was used ; and 
it may be of interest, at the risk of some repetition, to insert here the stages by which the 
decision to use it was arrived at : 

In the first instance (Case 338) a " Masonic collar " flap was taken from the chest, on 
two pedicles which were tubed at the time of the operation. 

Though successful, it was considered that in subjects of inferior physique the demand 
made on the blood supply might prove too great. 

Accordingly, in Case 364 another Masonic collar-flap the pedicles were tubed 
first, and the flap turned up after three weeks' interval. 

In Case 513, a unilateral area from chin to left ear required covering. After tubing, 
a long single-pedicle flap was turned up from the chest and applied to an area, rawed for 
its reception, upon the chin. Grave doubts were entertained as to its viability, at this 
stage ; but in the second stage the severance from its original base, and the spreading 
of the opened-out pedicle upon the cheek there was never a moment's misgiving. 
Apparently the introduction of a new blood supply into tissue (especially when it is grafted 
upon the face, the most vascular site of all) has a powerful stimulatory effect. 

In view of this experience it was decided (Case 565) to lessen the demands on the 
pedicle by shifting its upper end (its future base) closer to the first objective, to begin with. 

After an interval of three weeks for its establishment in its new situation, its lower 
end was brought up to the chin. The result of this manoeuvre was highly satisfactory ; 
when a firm hold had been taken upon the chin, the original base, plus an extra area 
from the posterior triangle of the neck, was swung up to the nose, and after a suitable interval 
the pedicle was opened out and spread upon the cheek. 

To return now to Case 1002. As the preliminary shifting of the upper end of the tube- 
pedicle seemed to be so helpful in the last case, it was decided here to adopt a similar plan. 
While considering the site of this preliminary shift, the author realised the futility of 
being wedded to flaps from below the face, the bases of which would always need shifting. 
Why not go higher at once ? 

It happened that in this case the area of hair-free skin behind the ear was relatively 
wide, and, further, was freckled in a manner similar to what remained of normal face 
skin ; and so a post-aural flap was decided upon. (It should be noted that this flap is not 
always available, nor, when available, is it always suitable.) 

To obtain sufficient width, the skin over the posterior surface of the pinna was removed 
in continuity with that over the mastoid, and the width was still further increased by the 
inclusion of a small area of hairy scalp a slight disability, but of no great import in a light- 
skinned subject. 

Having shifted the base of the flap first, the intention was to tube a portion of the neck 
and chest if necessary, and then swing this tube up to complete the facial restoration, the 
final blood supply IK ing through the new cheeks. 

On the left side, the scar tissue over the cheek was excised (the dissection in places 
going very deep), and the shape and size of the flap were nicely adjusted to fit this area. 



The requisite length of pedicle was carefully gauged, but the behaviour of flaps is not 
always susceptible of mathematical analysis, and the colour of the flap was anxiously watched 
during the process of dissection. When swung forward and sutured to its new position, 
the flap turned very blue, especially that portion from the pinna, and hot saline dressings 
were applied every two hours, beginning with the post-operative dressing. 

After twenty-four hours the flap appeared to be going gangrenous ; but a remarkable 
recovery occurred, and by the third day anxiety ceased. Only a small piece, from the 
hairy scalp, failed to take. 

Thiersch grafts, under moulded stent, were applied to the raw area behind the ear, but 
with small success, owing to insufficient fixation of the mould. 

On the right side the proceeding was similar, and the flap went through the same pre- 
carious period. Here the scar was dissected from the face in one piece, and was applied 
as a graft to the raw area behind the ear. After removal of slough, it was found that 
valuable islands of epithelium had become adherent, considerably assisting the healing 

On these healthy and natural-looking new cheeks, flaps can now be swung up from 
either side of the neck for the nose and chin. The eyelids will be dealt with by epithelial 

Note. These flaps are similar to the one employed in Case No. 215, p. 72, in the section 
on cheeks. 

FIGS. 757 and 758. On admission. 


Fio. 759. Case 1002. Excision of scar and flap outlined. 

l''n;s. 71)0 and 761. Restoration of both cheeks from post-aural region. 



CASE 565 

It is occasionally noticed that these epi- 
thelial grafts suffer from a subsequent con- 
traction, which would appear to be due to the 
fibrotic process continuing in the bed on which 
the graft is raised in other words, the graft- 
ing is probably done too soon. Disappointing 
results are therefore to be expected in very 
severe burns, when the scar-tissue formation 
is still active. Nevertheless, in order to get 
the eye protected by a covering, it is a correct 
procedure to perform one of these graft 
operations. It is easy to do another at a 
later date, and allowance should be made for 

In case No. 565 an excellent skin-graft 
to the right lower lid and inner canthus region 
resulted in 'a disappointment and a shrinking 
to less than half its area. This would appear 
to be due to the causes above mentioned. 

Photographs are attached illustrating the 
condition and area of the graft shortly after 
the removal of the mould, while that of three 
months later shows the contraction that has 

This case has been complicated by ulcers 
on the cornea, rendering immediate procedure 
to obtain a covering advisable. 

FIG. 762. On admission. 

Fio. 7G3. Shortly after outlay to 
right upper lid. 

FIG. 764. Three months later. 
The outlay has contracted. 

The next three cases are of burns, the interest of which lies in the 
repair of the eyelids, by the epithelial outlay operation. There is nothing 
special to describe about the operations, as they conform, in practically every 
detail, to the type operation in the beginning of the chapter. 


CASE 557 

Epithelial outlay operation for eyelids, performed on 16.5.18, fourteen months after 
the result of the burn. Photographs illustrating the eyes, closed and open, before and 
after treatment, require no description. 

Right eye. 


FIGS. 765 and 766. Before treatment. 

FI03. 767 and 768. Soon after operation. 

Flos. 769 and 7 70. Final result. 



CASE 633 

Case 633 shows the result of burns in action, received on board one of H.M. monitors. 
The nose and right ear were also burned and have not yet been treated ; but the ectropion 
of the eyelids has been cured by the epithelial outlay. 

The little fold observable in the open position after operation could be easily rectified 
by simple excision, without interfering with the result. 


Right eye. 


FIGS. 771 and 772. Before treatment. 

FIQS 773 and 774. After treatment. 


CASE 386 

This was the patient who stated that he had been burned by a German flame-thrower. 
But, as the accuracy of this information is not determined, the causative agent is 
regarded as unknown. From its appearance, one would judge it to be an acid burn. 

The main area affected was the chin, which was the seat of a large keloidal scar. Ex- 
tending from the extremity of this were two scar lines running in to the nasolabial fold. 
Tin- lower lip was markedly ectropic, the mucous membrane red, glazed and studded, with 
mucous vesicles. Below the chin scar the burn extended down the neck and chest, gradually 
diminishing in severity. On the face area involved the burn seems to have affected certain 
spots much more than others, and often an island of healthy skin would be lying at the 
bottom of a pit, the walls of which were composed of dense keloid. 

Treatment. The deep portion in the left nasolabial furrow was first excised and the 
skin approximated. Then the mass of the keloid on the chin was freely removed, together 
with a redundant portion of the lower lip. A flap, with its base towards the posterior 
triangle of the neck on the left side, was taken from the area as shown in the illustration, 
fig. 776, and was swung up to the chin. The whole of the pedicle was sewn into the neck, 
and, to make room for this, some of the scar tissue in the neck was cut as a flap and transposed 
downwards to fill up the raw area. The post-operative stage was interesting, on account 
of the effect of electro-therapeutic measures carried out soon after the operation ; they 
were mostly in the form of the vacuum high-frequency electrode. At the end of the third 
day a considerable reaction was noticeable in the way of increased blood supply to the 
flap. This may, or may not, have had a detrimental effect, as the return veins and efferent 
lymphatics were not sufficiently developed to carry off the fluids of this reaction, and stasis 
became apparent on the third day. To aid the efferent circulation I discontinued the electro- 
therapeutical measures, and pricked the bluer parts with a fine, sharp needle. Over this 
pricked area Bier's cupping was applied, and much blood and lymph were extracted. The 
colour and circulation immediately returned right to the extremity of the flap, but twenty- 
four hours afterwards the blueness had returned to a minor degree along the extremity of 
the flap and was not any longer amenable to treatment. 

The amount of the flap lost by gangrene is well shown in the photograph, fig. 776. This 
loss was sufficient to cause a slight pulling down of the lip opposite that spot, and, to cure 
this and raise the lip, a nasolabial flap was later swung down below the margin of the 
lower lip. At the same time the thick scar band from the right aspect of the mandible, 
extending down the neck to the clavicle, was treated by skin-graft in the following manner, 
which is similar to the treatment for ectropic conditions of the eyelids. An incision was 
made right across the scar part, which was dissected out. The cavity was deepened until 
the neck could be stretched and extended, the usual mould of the cavity taken, and a skin- 
graft wrapped around it. The mould on this occasion was made of paraffin wax, and the 
skin-graft was a Wolfe graft. 

The result was satisfactory both as regards appearance and function. 

7.12.17. Operation. Main principle. Excision of scar tissue and replacement by 
a long broad chest-flap, having its base of attachment in the left posterior triangle of the 

Details. The scar in the left nasolabial furrow was excised and the skin approxi- 
mated. Primary union. That on the right was left untouched. The excision of the scar 
commenced at each corner of the mouth and was carried outwards until healthy skin was 
reached. A portion of the everted mucous membrane of the lower lip was excised with 
the scar tissue about \ in. The scar tissue varied in depth ; in places there was even 
healthy skin ; in others, the scar tissue extended deep into the muscular layer and was 
quite \ in. in thickness. The long flap was outlined as in the diagram and swung into 
position. It was stitched all along the healthy margin of the skin and mucous membrane. 
In order to fit it in better, the portion of the front aspect of the neck which contained a 
considerable amount of scar tissue was raised and swung downwards to help fill up the gap 
on the chest. 



FIG. 775. On admission. 

Fio. 776. Chest flap to chin. (See text.) 

Progress. The blood supply of the flap was good, but considerable swelling occurred 
on the second and third days after the operation, which was due to the following causes : 

Lymphatic and venous stasis of the extremities of the flap occurred. Blood and serum 
collected under the flap, which was therefore drained beneath the chin. Portions of the 
flap namely, just below the lip, and another patch on the right and another smaller patch 
on the left became blue with a tendency to become gangrenous. The vacuum high- 
frequency electrode was applied to the flap for the first three days after the operation. 
On the third day pricking of the blue portions of the flap was resorted to and Bier's cupping 
was carried out. Large quantities of lymph and blood were drained away, and the whole 
contour of the flap improved considerably, almost to the normal. Hot fomentations were 
applied and the electrical treatment discontinued. This treatment was continued for the 
next two or three days, but gradually a line of demarcation appeared round each place, 
followed by suppuration and sloughing. 

17.6.17. Condition. There was some ectropion of lower lip, right corner, due to the 
small portion of the chest-flap which sloughed at the previous operation. In addition, 
along the right-hand edge of this flap was a thick band of scar tissue which prevented the 
head being freely extended. 

17.0.18. Operation. (1) After excision of scar near the angle of the mouth, flap 
" A " from the right nasolabial fold was brought down to raise the corner of the lip. (2) 
To divide the band of scar tissue satisfactorily a free incision was made across it, and a 
cavity made into which a mould of a high-melting paraffin was inserted. A whole-thickness 
graft from the arm was wrapped round it and the whole buried. There resulted complete 
relief from the limitation of extension of the head, and a slight improvement in the 



Fio. 777. Indicating site of second operations. A whole- 
thickness graft was applied after excision of the scar "B." 

FIG. 778. Note scar near right corner of mouth. 

Fia. 779. Final : After excision of scar and descending nasolabial flap. 


DEFECTS and burns of the pinna form a small proportion of facial injuries. 
The gunshot injuries met with may be thus classified : Scars, perforations, 
marginal losses, losses of the lobule, and large and total losses of the pinna. 

Scars do not always need treatment : owing to the breadth of the patient's 
head relative to the width apart of the observer's eyes and the distance at which 
ordinary conversation is conducted, it happens that both ears are seldom seen 
in the same glance. Consequently, minor degrees of asymmetry are negligible. 

Perforations of the concha readily lend themselves to repair by means of 
a flap swung from the back of the pinna, as indicated in figs. 780-783. 

Fio. 780. Perfora- 
tion : Ascending 
flap outlined. 

Fio. 781. Flap 
being swung 

Fio. 782. Per- 

Fio. 783 . 
Raw area 

Marginal losses present more difficulty : the contour of the helix must 
be restored. In small losses the author has successfully applied the principle 
of turning up a flap from the back of the pinna containing a previously buried 
piece of cartilage, after the method outlined in figures 784-787. Case 
No. 622 was treated in this manner. (See photographs, figs. 788 and 789.) 

If merely a small piece is required, the cartilage is taken from the same 
or the other concha, where experience shows that the removal is not followed 
by disfigurement. Otherwise, it is taken from the rib and suitably shaped. 



CASE 622 

Operation notes : 

1.12.18. Piece of cartilage from anti-hdix of left car was removed subcutaneously 
of the necessary length and curve to complete the gap in the pinna. (This through an 
incision along the border of the anterior surface.) The cartilage was now imbedded into 
a flap on the posterior aspect of the pinna, which is to be swung upwards as a skin-cartilage 
flap later. 

3.3.19. Replacement of missing portion of helix of left ear by flap from post- 
auricular region. 

21.5.19. Piece of cartilage from right anti-helix dissected and implanted to form 
free border of new portion of left ear. 

1.6.19. The top edge i s curved back a little. Patient not desirous of further treatment. 

FlO. 784. Showing 
defect ; Cartilage 
implanted and 
flap outlined. 

FIG. 785. Flap 
being swung 

FIG. 786. Flap 
in position. 

FIG. 787. Raw 
area grafted. 
(In Case 622 a 
flap was used.) 

Fio 7S8. Showing marginal defect. 

Fio. 789. Present condition. Requires trimming 
up to complete. 



Larger marginal losses are amenable to a type of repair comparable with 
this, but on a larger scale. 

Here, as in the cases of total loss, the principle employed is the preliminary 
reconstruction of the missing organ by imbedding cartilage under the skin 
bordering on the defect, followed by the elevation of the new pinna into position 
as a second step. 

In Case No. 3,357, a subtotal loss (see figs. 795 and 796), the support of the 
new pinna was accurately fashioned in cartilage taken from the seventh and 
eighth ribs. 

This was inserted beneath the hair-free skin over the mastoid process and 
the skin pressed down into its irregularities by means of Stent. Unfortunately, 
the pressure thus applied proved too much for the blood supply, and much of 
the cartilage forming the helix and anti-helix sloughed. The result of this 
stage is shown in fig. 797. 

Four months later a flap containing this cartilage was swung outward 
and forward on a pedicle consisting of the stump of the original pinna. 

The resulting raw area on the back of the new pinna and over the mastoid 
process was covered by a flap taken from the posterior triangle of the neck. 
The man's present condition is seen in fig. 798. The diagrams .of these stages 
are indicated in figs. 790-794. 

Operation notes of this case are as follows : 

13.2.19. Otoplasty. Implantation of cartilage to left ear. 
6.6.19. Plastic to left ear. 

6.8.19. Blood examined. Pathologist'*- report: strong positive, 
some bearing on the fate of the graft.) 

(This may have 

FIQ. 790. Rib - cartilage 
shaped to represent miss- 
ing portion. 

FIG. 791 .Shaped car 
tilage graft inserted 

FIG. 792. Skin sutured over the graft. 
Stent was applied to press the skin 
accurately into the hollows. 



()/ CASE 3357 

Fio. 793. Operation four months after cartilage im- 
plant. Skin-cartilage flap swung forward. Raw 
area to be covered by flap from posterior triangle. 

Fio. 795. Showing subtotal loss of pinna. 

FIG. 794. Suture. The raw area on the neck 
was easily covered by advancement of the edges 

FIG. 796. Lateral view. 

FIG. 797. After cartilage implant. (Much of it 
sloughed. ? due to blood condition. See notes.) 

FIG. 798. Present condition. 



Loss of the lobule has been made good by means of a post-auricular flap which is made 
to form the anterior surface of the lobule, the posterior covering being supplied by skin- 
grafting the raw area. 

Case No. 2251 was treated in this way, and the stages in the sufficiently 
good result obtained are seen in figs. 803-805. 

The operation notes for this case are as follows : 

6.2.19. Post-auricular flap incised and turned up, having as its pedicle the remaining 
portion of the ear. An incision was then made about 4 in. long at lower adherent 
portion of ear, and part of the flap was sutured to this incision. The raw portion of the 
flap and the bed of the flap were covered by a Thiersch graft under stent. 

14.5.19. The lobular portion of the left ear was advanced about J in. by a vertical 

Diagrams illustrative of the method employed in this case are given, and 
diagrams for an alternative method are also shown. 

FIG. 799. Showing defect, 
and outlining of flap. 

FIG. 800. Flap being 
swung forward. 

FIG. 801. Suture. 

FIG. 802. Graft to 
raw area. 

It will be realised that the diagrams throughout this section are what 
might be termed " ultra-diagrammatic." They were prepared from a verbal 
description, as it was found that photos of some of the stages failed to give 
any idea of the procedure adopted. 




CASE 2251 

Fio. 803. Showing the defect. 

Fia. 804. Soon after plastic. 
Side view. 

Fia. 805. Soon after plastic. Posterior view. The Thiersch graft failed to take in parts. 

Fio. 800. Showing defect, 
and proposed flap outlined. 

Kid. 81)7. Flap swung down FIG. 808. Suture. Fio. 809. Raw area 

and being doubled upon itself. grafted. 



Burns are often followed by adhesions of the remnants of the pinna to the 
skin over the mastoid process. Here the epithelial inlay is indicated, and in 
cases with small loss of substance the freeing of the pinna produces a sufficiently 
satisfactory result. 

CASE 3359 

FIG. 810. Shows result of epithelial outlay used as a means of freeing the upper portion of the 
pinna which was adherent to the scalp. (Photo of pre-operative condition not available.) 
The limits of the outlay can be seen with difficulty. 

Operation notes : 

20.9.18. Right pinna dissected from scalp to which its upper portion was adherent. 
Mould of raw cavity thus formed taken with warm stent. Thiersch wrapped round stent, 
raw area outwards, and placed in the cavity. Free edge of pinna sewn back to original 
position against scalp. 

30.9.18. Stitches cut, stent removed. Graft taken nicely. 

In these burnt cases there is usually so much concomitant scarring that 
local flaps are not available, and the question of the expediency of restoring 
the pinna by neck or chest flaps is intimately associated with the problem 
of the whole facial restoration. It is found, as a matter of practice, that the 
ear defect in a severe burn is a minor part of the disfigurement, and does not 
usually justify the time and trouble that its cure requires. 




THE application of the methods described and discussed in the previous pages 
will, in the author's opinion, have considerable effect upon the possibilities of 
plastic surgery amongst the civil community. It may be also, that, apart from 
the much wider field of deformities which will be brought into the class in which 
successful restoration can be applied, the treatment of the disease itself, in 
addition to the deformity caused by the disease or injury, will be modified. 
Thus, when it is demonstrated that successful and cosmetic rhinoplasty is an 
operation that can be counted on with reasonable certainty, the early treatment 
of lupus may be modified in the direction of complete excision of the affected 
area regardless of the deformity so caused. 

Should this suggested line of treatment be practical in removing the disease, 
years of local therapy will be dispensed with. 

Many of the cases that the author has treated for healed lupus deformities 
had a history lasting for ten or fifteen years, and presented tissues so scarred 
and fibrosed that the work of the plastic surgeon was greatly hampered. Had 
it been possible, in such cases, to have excised the tip of the nose with the 
adjacent lymphatic tracts in the naso-labial folds completely in the early stages, 
successful nasal reconstruction, with far less resultant deformity, could be reason- 
ably guaranteed, and the treatment markedly shortened. 

Taking the situation as it is at present, there are many thousands^of cases 
in the world of healed lupus whose scarred facial remains are so distorted that 
most of them have to live a secluded or semi-secluded life. 

Even in this scarred class of case gratifying results of rhinoplasty have 
already been obtained by the author. 

It is found advisable to modify somewhat the plan of treatment in these 
cases, particularly in regard to two points. 

One of these points is that the inturned flaps to form the skin lining of the 
new nose have to be so designed that they have a larger blood supply than is 
usually deemed sufficient in the non-lupus cases. 

The second point is that the tissues are more liable to suppurative troubles, 
and it is unwise to take the risk of immediate cartilage implantation between two 
epithelial flaps. 

Examples of this are given among the cases which follow. 



Turning to syphilis, as the principal peace-time destroyer of the nose, the 
author has not yet seen a case which is not amenable to the methods evolved 
by him during the war. 

These cases appear to be quite comparable with the war injuries, provided 
that diagnosis is made of the tissue lost, and repair is designed to make good 
such losses ; and the results are very encouraging. 

In one of the cases illustrated the main loss of tissue was in the mucous 
membrane lining. There was also concomitant loss of the cartilage supports, 
while the skin covering was almost intact. 

The provision of a skin-graft for the lining and cartilage for the support 
was sufficient to produce a good result. 

In a second case of hereditary syphilis total loss of the nose existed. All 
structures, including the bony supports, lateral and central, had been destroyed 
by the disease. The early result of rhinoplasty in this case is illustrated. 

Depressed fractures of the nose, either with or without lateral deviation, are 
best treated by cartilage implantation. In some cases, however, especially 
where there is lateral deviation only, it is possible to refracture the nose and 
set it straight. Naturally the surgeon will pay attention to the freeing of the 
airway in all cases. 

In regard to hare-lips, the author does not intend to discuss the early 
operative treatment which is so fully known and appreciated by the surgical pro- 
fession. It has, however, occurred in the author's practice to treat a number 
of cases the results of whose early operations, good though they are, were 
capable of being treated on lines similar to those suggested in this book. 
Corrections of the line and the contour of the new lip, and the position of 
the columella and alse can quite often be effected, while interpolation of an 
epithelial inlay will often produce a contour which effects an astonishing improve- 

Burns of the face are a common injury in civil as in military practice, 
and do not require special treatment in this chapter. 

The author's operation for epithelial outlay has already produced a great 
relief to patients afflicted with cicatricial ectropion. The possibility of removal 
of nsevoid disfigurements springs to one's mind, and many such are amenable to 
the newer methods. 

Rhinophyma obviously lends itself to most gratifying rhinoplasty, either by 
forehead flap or Wolfe graft. 

Over-developed and under-developed noses can be corrected without scarring 
or any secondary disfigurement. 

A few examples of completed and semi-completed cases of facial dis- 
figurement are appended. 


The principles the development of which has been indicated by this book 
are, naturally enough, not applicable merely to facial surgery. The principle 
of tubing the pedicle of a flap has, at one bound, pointed the way to dealing 
with a reasonable loss of skin, traumatic or pathological, from any part of the 
body surface. Skin may be brought by this means from any part to any other 
in one step for distances not exceeding ten inches otherwise in several 
steps, the source and direction of the blood supply being changed each time 
the existing base becomes the free end. 

It should even be possible to establish a satisfactory ambulatory treat- 
ment for varicose ulcers. 

The surgeon may now deal fearlessly with almost any ulcer that can be 
excised or rendered clean, secure in the knowledge that a covering of healthy 
skin can be provided for the raw area resulting from his interference. Further, 
it is not too much to say that contractures should not now be allowed to occur 
after burns. The impending deformity can be anticipated by a thorough 
excision of scar tissue followed by the use of skin -flaps, tubed, say, three weeks 
before, from the periphery of the defect. Webbed fingers and other similar 
deformities should present problems now greatly simplified. 

The tubed flap may be made to bear within its substance or upon its sur- 
face supplies of skin, hair, mucosa, fat, connective tissue, bone, cartilage or 
blood-vessels in fact any of the less highly organised tissues. There is scope 
for the transplantation of such material in the restoration, not only of surface, 
but of tissues bordering thereon. The gap left by the removal of the female 
breast should be remediable in terms of tubed flaps designed to carry large 
masses of fat, e.g. from the buttock, along the lines indicated in figs. 811 to 816. 

The principle of replacement in kind for lining membranes as for coverings 
finds a field wherever trauma or disease have transgressed the barriers that 
separate these two types of tissue. Thus a severe degree of stricture of the 
urethra should lend itself to excision followed by the reconstitution of the 
mucosal lumen by a Thiersch graft applied by some modification of the Esser 

In this connection, pre-natal disease offers a vast field. Conditions such 
as Ectopia Vesicte, Hypospadias, Meningoccele, Imperforate Anus, and various 
forms of fistulse offer scope for the application of these principles in combination. 



Flo. 811. Breast excised ; flap outlined. 

Fio. 812. The pediole "tubed." 

tt< -The fat-carrying flap being swung up to the defect,. 




FIG. 814. The flap sutured into place. 

FIG. 815. The pedicle severed, opened out, and being 
swung up to reinforce the flap. 

FIGS. 81 1 and 812 represent the first stage, 
which would be followed by an interval 
of at least ten days. 

FIGS. 813 and 814 represent the second 
stage, also followed by a ten-day 

FIGS. 8 1 5 and 8 1 6 represent the final stages. 

FIG. 810. Suture. 



FIGS. 817 and 818. Hereditary specific disease : total destruction of nose. In these photographs a piece of 
cartilage has been imbedded above the nasal aperture, and a thin piece laterally in each naso-labial fold to form 
the bridge and ala supports respectively. 

Flos. 819 and 820. Early result : Rhinoplasty from the forehead by tubed pedicle method. 

Fio. 821. Dog bite of lip. 

Fid 822. Result of sewing small flap into lip 
to replace scar. 



Fios. 823 and 824. Acquired destruction of nose. (Paraffin had been injected to raise the bridge.) 

FIG. 826. 

FIG. 825. FIG. 827. 

FIG. 825. Intermediate. Intermediate stage, showing result of skin-graft to inside of nose. The skin-graft was 
inserted from an incision beneath the lip, held in position by stent mould, which, in itself, was held in position by 
a dental splint passing through an existing palatal perforation. The nose is here seen supported by a dental 
appliance taking its purchase from the upper teeth, and supporting the bridge through the palate. This 
appliance was made and designed by Major Kenneth Russell, A.A.D.C. 

FIGS. 820 and 827. Finals: Result after cartilage implantation. Cartilage taken from another case and inserted 
through the tip. The appliance to the nose is worn no longer, as the cartilage is sufficient. 



Fios. 828 and 829. Traumatic loss of the tip, eolumella, and also of the nose. Much forehead scarring, 
and part loss of upper lip. (There had been previous attempts at restoration.) 

FIGS. 830 and 831. Finals : Result of rhinoplasty. 

I n.. s:t:!. Kxrussive prominence of nasal bridge. 

Flo. 833. After operation by excision. 



FIGS. 834 and 835. Traumatic deformity of nose. 

FIGS. 830 and 837. Result of cartilage implantation. 

FIG. 838. Arrested development of nose 
from natal injury. 

FIG. 839. Result after cartilage 



FIGS. 840 and 841. Deformity of nose following lup 

Fio. 842. Rhinoplasty by temporal artery 
tube pedicle flap. 

FIQS. 843 and 844. Result of rhinoplasty. 


Acid burns, 347 
Advancing flaps, 19, 20 

in rhinoplasty, 214, 248 

in upper lip injuries, 101 
After treatment, 34 
Airman's burns, 347, 372-375 
Air-way, nasal, bleeding into, 27, 28 

clearing of, 213 

establishment of, 271, 278 

Hewitt's, 27, 28 

obstructed, ansesthesia with, 27 
due to loss of columella, 202 
Ala, injury to, author's method of treatment, 258 
Wolfe graft in, 247 

loss of, 246, 398 

cases illustrating, 247-257 

new, provision of, 252, 255, 263 

operation on, 225 

partial loss of, 267, 269 

pug-nose deformity of, 230, 231 
cases illustrating, 232, 237-239 

skin lining for, 212 
Alveolar process, loss of, 64 
Alveolus, palatal injuries involving, 207 
Anaesthesia, 23 

chloroform and oxygen, in sitting-up position, 

coughing during, 26 

for rhinoplasty, 27 

intra-tracheal, 23 

nasal tube for, 25 

oil-ether, 27, 28 

paraldehyde, 28 

position during, 24 
Anus, imperforate, 393 
Appliances. See Prosthetic appliances 
Approximating hooks, 50 
Ascending flaps, 19 

for upper lip injuries, 77, 78, 80 

in ear injuries, 381 

in eye injuries, 314 
Asepsis, during suture, 33 
Autologous cartilage graft to nasal bridge, 293 
Autologous osteochrondral mandible graft, 179, 
180, 181 

Ball cartilage eyes, 336, 339 
Bird-beak type of nose, 217 
Blepharoplasty, inferior, 313 

flaps in, 314 
principles of, 313 
superior, 329 
cases illustrating, 330-331 

Blepharoplasty, principles of, 329 

suture in, 315 

Blood supply of Haps, 30, 77-79 
Bone grafts, 183-189 

anaesthesia during, 28 

restricted use of, 12 

to the mandible, methods, 177-180 
Bony chin, loss of, 123 
Bony loss, estimation of, 5 

extensive, 198 

in cheek and jaw injuries, 52, 64 
cases illustrating, 52-63, 64-74 

in eye injuries, 301, 304, 306, 308 

prosthetic replacement of, 200 
Bridge pedicle Haps in upper lip injuries, 98, 115. 

See also Pedicle 
Buccal fistula, 50, 70 
Buccal orifice, widening of, 132 
Buccal restoration, 8, 9 
Burns, cases illustrating, 353-380 

after treatment of, 351 

causes and varieties of, 347 

facial, 18, 347, 349 

causing microstoma, 123 

of the ears, 347, 381 

of the eyelids, 347, 349 

treatment of, 348, 349 
errors in, 351 

Canthoplasty, 324, 325 

method of obtaining, 13 
Cartilage flaps, in eye injuries, 315 

in nose injuries, 217, 230, 231, 234, 258 

in pinna injuries, 382, 384 
Cartilage grafts, 12, 13 

homologous and autologous, 13, 14, 15 

in cheek injuries, 45 

in eye injuries, 303, 307, 309, 338, 344 

in operation for orbicularis palsy, 344 

in pinna injuries, 383 

Cartilage implants, for depressed fractures of 
the nose, 392 

in extensive cheek injuries, 73, 74 

in eye injuries, 336 

in inferior blepharoplasty, 314, 315 

in pinna injuries, 383-384 

in nose injuries, 212, 219, 223, 227, 264, 266, 
268, 399 

to malar region, 309 

Cartilaginous supports, skin-flaps used in associa- 
tion with, 22 
Caterpillar movement, in nose repair, 250, 251 




Catgut sutures, 32 

Olluloul plate, for facial contour, 12 

in cheek repair, 52, 53. ."> I 
Celluloid supports, Indian rhinoplasty over 
Check, adherent to palate, 207 

excision and incision of scars of, 61, *>6, >J. 
loss of bony framework of, 52 
mucous flap from inside of, 139 
reconstruction after nasal operation, 212 
repair of the, 37 

Cheek-Haps, in lip injuries, 87, 129, 1 
in injuries to palate, 207 
in rhinoplasty, 3 
Cheek injuries, 37-38 

celluloid implantations in, 53, 54 
complete loss in, 71, 72 
depressed scars, 37, 38 

cases illustrating, 39-41 
extensive destruction in, 72 
extensive loss of soft parts, appliance used in, 


fat-grafts in, 44 

hollow filled by fat-graft in, 115 
horsehair mattress sutures in, 57 
loss of soft tissue only, 42 
cases illustrating, 42-51 
restoration from post-aural region, 374 
sutures in, 63, 65 
teeth carried through, 50 
total loss of nose with, 294 
triangular opening in, 60 j 
with loss of bone, 52, 62 

cases illustrating, 52-63 
with superior maxillary loss, 64 

cases illustrating, 64-74 

Chest, tube pedicle rhinoplasty from, 212, 213 
Chest-Haps, for facial losses, 14, 352 
in rhinoplasty, 212, 213 
to chin, 370, 379 

Chin, anesthesia during operations on, 26 
new, operation for provision of, 175 
prosthetic replacement of, 174 
viability of llaps near, 22 
Chin-flaps, for upper lip injuries, 78, 80, 90 
Chin injuries, 123, 124, 158 

cases illustrating, 125-189 
chest llaps in, 370, 379 
descending nasolabial cutaneo-muscular flap in, 


excision of scar tissue in, 165 
extensive loss in, 162, 168, 172 
forehead flap in, 176 
neck-Hap in, 159 
scalp-Hap in, 170 
scar excision in, 164, 167 
soft tissues, 165, 166, 172 
suture in, 157, 163, 164, 167 
Chloroform and oxygen anaesthesia, methods, 24- 


technique, '2 I 
Civil rases, plastic surgery in, 391 

illustrations of. :t'.l 100 

Cleft palate, aiia-slhesia during operations on, 25 
Colmnella. and upper lip repair, 82 
artificial, 203. 27.'), 2*7 
celluloid support to, 22li 
deficiency of, 253 

Columclla. detachment of, 252 

loss of, 398 

obstructed airway due to loss of, 202 

operation on, 95 
Concha, perforation of, 381 
Conjunctiva, deficiency of, 332 

incision through, 332, 333 
Contour. See Facial contour 
Cordite burns, 347 

Coughing, prevention during anaesthesia, ^o 
Covering tissues, 16 

Cranial defects, loss of bone constituting, 301 
Cyanosis during anaesthesia, 24, 25 

Deformity, scar tissue in relation to, 30 
Deglutition, impaired, 124 
Dental appliances in palatal injuries, 205, 
Dental fixation, nasal splint with, 201 
Dental splints, 194 

in mandible injuries, 177, 195 
use of, 194-196 
use in epithelial inlay, 10 
Dental sulcus, reformation of, 197 

prevention of encroachment of soft tissue 

upon, 196 

preservation of, 194, 195 
Dental surgeon, role of, 6, 7, 10, 193, 206 
Dentures, 193 
functional, 200 

in upper lip injuries, 82, 83, 92, 93 
prosthetic support of, 200 
with artificial pre-maxilla, 92 
Depressed scars of the cheek, 37-38 
Depressor musculature, for the jaw, 123, 124 
Descending flaps in eye injuries, 314 
in lower lip injuries, 142, 148, 150, 154 
in upper lip injuries, 78, 97, 103 
Descending naso-iabial flaps, 19 
Diagnosis, data for, 5 

depending on accurate estimation of tissues 

lost, 146 
mistakes in, 4 

Digastric, epithelialisation of, 124 
Dressings, 33 

Ears, burns of, 347, 381 

flaps from, in blepharoplasty, 313 

injuries to, 381 
flaps in, 381 

restoration of lobule of, 386 

See also Pinna injuries 
Ectopia vesicse, 393 
Ectropic conditions, epithelial outlay an, K 

modification of epithelial inlay in cure of, 9 
Ectropion, 354, 355, 358, 361, 362, 363 

cicatricial, following burns, 349, 354 
treatment of, 349 

of lower lip, 125 

of upper lip, 115 

traumatic, 313 

Wolfe graft relieving, 366 
Electrical post-operative treatment, 34 
Electric burns, 348 
Entropion, 332 

Epicanthus following burns, 351 
Epilation, 9 



Epiphora, due to orbicularis palsv, 344 
Epithelial inlay, 9-12 

advantages of, 200 

anaesthesia during, 25 

for stenosis of anterior nares, 213 

in eye injuries, 325, 332 

in mouth injuries, 200 

new nasal tip and alse by, 263 

splint with ilange to maintain stent for, 197 
Epithelial lining, in nose injuries, 221 

provision of, 8 
Epithelial outlay, 16 

in ectropic conditions, 16 

in eye injuries, stages of, 350, 363 

in eyelid injuries, 289, 330, 331, 349, 358, 376 

in pinna injuries, 387 

stages in, 17 

Esser inlay. See Epithelial inlay 
Ether anaesthesia, 27 
Ether swab, preparation of skin for operation by, 


Examination of cases, principles of, 4 
Excision of facial wounds, 6 
Extra-oral appliances in nose injuries, 201, 202, 

Eye injuries, 203 

bony loss in, 304, 306, 308 

cartilage grafts in. 303, 307, 309, 338 

cranial loss in, 306 

epithelial inlay in, 325, 332 

epithelial outlay in, 349 
stages in, 350, 363 

failures in operations in, causes of, 322 

flaps in, 304, 318, 328, 358 

infra-orbital depression, 311 

pedicle flaps in, 309, 358, 362, 365, 369 

prosthetic appliances in, 203-205, 335 

orbital ring, 301 

scar excision in, 202 

suture in, 302, 308, 323 

temporal flap in, 308 

Tripier operation in, 59 

See also Blepharoplasty 
Eyebrow, artificial, 301 

loss of, 301, 304 

replacement of, 18, 301 
Eyes, artificial, 336, 337 

insertion of, 204, 340, 342 
cases illustrating, 338-343 

burns of, 347-349 

flaps near, 19 

paralysis of muscles of, 344 

primary enucleation of, 336 
Eyelashes, tattooing for, 329 
Eyelids, artificial, construction of, 204 

bums of, 347, 349 

after treatment of, 351 
cases illustrating, 353-380 
errors in treatment of, 351 
treatment of, 348, 349 

destruction of, 313 

distorted, replacement of, 316 

ectropion of, epithelial outlay in operation for, 
16, 17 

epithelial outlay to, 289, 358, 376 

incision in, 317 

injuries to, 313 

Eyelids, injuries to, cases illustrating, 316-331 
lower, lack of muscle power in, 57 
lymph-oedema of, 326, 328 
operations on, 313 
rebuilding of ocular aspect of, 8 
reproduction of action of, 344 
tattooing of, 329 
upper, drooping of, 204 

flap from, 314 

loss of, 329, 330, 331 

lymph-oedema of, 58 

reconstruction of, 329 
Eyesockets, contracted, 332 

following defective rhinoplasty, 8 
epithelialisation of, 203, 343 

appliance for, 204 
injuries of, 332 

cases illustrating, 334 
inlay, 325 
replacement of, 74 
sunken, 336, 341 

cases illustrating, 338-343 
Tripier operation on, 58, 59 

Face, burns of, 18, 347, 349 
cases illustrating, 353-380 
errors in treatment of, 351 
treatment of, 348, 349 

deformity of upper part of, 194 

destruction of greater portion of, 72 

scars of, plastic treatment of, 391 
Facial contour, building up of, 12-14, 193-195 
skin-grafts in, 16 

fat and muscle flaps for, 14, 30 

loss of, extraordinary example of, 71, 72 

observations on, 12 

scar tissue and, 30 
Facial scars, invisible, 33 

Facial wounds, avoidance of secondary haemor- 
rhage in, 7 

cartilage grafts in, 14 

early treatment of, 5- 

excision of, 6 

plan of restoration in, 8 

planning the late repair of, 7 

supporting structure for, 12 

suture for closure of, 32 
Failures in plastic surgery, to what due, 4 
Fat-flaps, 30 

in restoration of contour, 14, 30 
Fat-graft, hollow in cheek filled by, 115 

to cheek, 44 

use of, 14, 16 

Fat implants, in eye injuries, 336 
Fatigue, prevention of, during operation, 29 
Fistula, buccal, 50, 70 
Flame-thrower, burns from, 348 
Flanges for splints and dentures, 194, 196, 197 
Flaps, about the eyes, 19 

advancing, 19 

ascending, for lip injuries, 77-78 

blood supply of, 30, 77-79 

cartilage supports and, 22 

descending, for upper lip injuries, 78 

descending naso-labial, 19 

early cutting of, not recommended, 6 

for facial burns, 352 , 



Hups. forehead, 18, 176, 282 

grafts sometimes more suitable than, 22 

hair-l)caring, 9, 77 

in chin injuries, 158, 160, 163, 170, 173, 176 

indications for, 16 

in car injuries, 381 

in eye injuries, 304, 313, 314, 318, 324, 358, 

in inferior blepharoplasty, 313, 314, 315 

in injuries to palate, 207 

in lower lip injuries, 125, 127, 129, 141, 148, 

in mouth injuries, 94 

in rhinoplasty, 211, 213, 217, 219, 230, 234, 248, 

in pinna injuries, 381, 385, 386 

in upper lip injuries, 78-82, 89 

near the chin, 22 

oedema associated with, 22, 34 

preparation of areas for, 29 

preservation of the life of, 22 

principles of, 393 

skin-muscle-mucous membrane, 148 

suture and, 32, 33 

transposed, 19 

tubed, 19, 21, 213, 393 

viability of, 22 
Forceps, for suture, 31 

Forehead, grafting of raw area on, after rhino- 
plasty, method, 18 
Forehead, skin-graft on, 297 

Wolfe graft to, 273 
Forehead flaps, in chin injuries, 176 

in rhinoplasty, 3, 213, 275, 279, 282, 396 
Foreign bodies, irritating tissues, 12 
Fornix, lower, loss of, 335, 338 
Frontal bone, injury to, with eyebrow loss, 304 
Function, restoration of, importance of, 8 
scar tissue impeding, 30 

Glabellar region, cartilage imbedded over, 271 
flaps from, in rhinoplasty, 214, 215, 217 
prominence in, 223 

Glass eye, skin-covered, insertion of, 340, 342 

Grafts. See Skin-grafts 

Granulation, prevention of, 6 

Hiemorrhage, during administration of anaes- 
thetics, 27 

into air-ways, 27, 28 

prevention of, during operation, 29 

secondary, avoidance of, 7 
Hair-bearing flaps, 9, 77-79 

for lip injuries, 77 
Hare-lip, 92 

plastic treatment of, 392 
Hare-lip type of injury, 106, 123, 124 
Helix, restoration of contour of, 381 
Hewitt's air-way, 27, 28 
Hooks, approximating, 50 
Horsehair suture, 31, 57 
Hyoscinc MS preliminary hypodermic, 27 
Hypospadias, 393 

Ilium grafts, 1S8, 189 

to the mandible, 178, 179, 180, 188, 189 
Infra-orbital depression, 311 

Intra-oral prosthetic appliances, 201 

Intra-nasal supports, vulcanite, 276 

Intra-tracheal amesthesia, 23 

Invisible scars, 32 

Iodine, preparation of skin by, for operation, 29 

Japanese silkworm gut, 32 
Jaw, anaesthesia for operations on, 27 
injuries to, 46, 124, 134 
artificial pre-maxilla in, 92 
extensive loss in, 70, 71 
new, depressor musculature for, 123, 124 
ramus of, ulceration of membrane over, 180 
upper, loss of bony support of, 64 

Kahn's tube for administration of anaesthetics, 

25, 26 
Keloid scar of upper lip, 109 

Labiogingival sulcus, re-creation of, 9, 182 

Lachrymation, 344 

Laryngotomy, 26 

Lining membrane for deepened sulcus, 9 

for mucous cavities, provision of, 3, 8 

provision of, methods of, 9, 10 
Lip injuries, adherence to palate in, 207 

backward displacement in, 87 

cheek-flaps in, 87 

deformity with partial loss of nasal bridge and 
ala, 240 

dog bite, 396 

flaps in, 84, 85 

outer third drawn upwards and inwards, 60 

repair and replacement in, 77, 80, 82, 83, 151, 

152, 156, 175 
suture in, 85, 242 

vermilion border in repair of, 9, 81, 139, 151, 

153, 156 

cases illustrating, 138-139 

with cheek destruction, 48, 49, 56, 57 
Lip injuries, lower, 82, 123-124 

anaesthesia during operations in, 26 

bone grafting to the mandible in, 177-180 

cases illustrating, 125-189 

central portion, cases illustrating, 134-137 

cheek-flap in, 129, 139, 141 

descending naso-labial flaps in, 142, 150 

diagnosis dependent on accurate estimation 
of tissues lost, 146 

ectropion in, 125 

lack of control in, 124 

mucous flaps in, 152, 156 

naso-labial flaps in, 142, 148, 150, 154 

neck-flap in, 159 

provision of new lip in, 159, 169, 175 

scar excision in, 135-137, 141, 143 

suture in, 125, 130, 141, 149 
Lip injuries, upper, 7782 

anaesthesia during operations on, 24 

bridge pedicle flap in, 115 

cases illustrating, 83-119 

chin-flaps in, 90 

complete loss in, 7, 84, 85, 87 

dentures in, 82, 92, 93 

descending flaps in, 97, 103 

ectropion in, 115 

hair-bearing flaps for, 77-79 



Lip injuries, Keloid scar in, 109 

laceration and drooping in, support for, 194 

loss of soft tissue in, appliance for, 195 

mucous (lap in, to lower lip, 153 

nasal flaps in, 90 

prosthetic appliance in, 85, 88 

provision of mucous membrane in, 81 

repair in, columella in relation to, 82 

secondary corrections in, 80 

six-flap operation in, 89 

suture in, 93, 97, 101, 103 

total loss in, 82, 83 
Lupus, deformity of nose following, 400 

plastic treatment of, 391 
Lymphatic stasis, 22 

Malar, cartilage implant to, 309 

loss of, 54, 301 

large hollow produced by, 58 

partial loss of, 46 

simulation of, 16 
Mandible injuries, 177 

anaesthesia during operations for, 24, 26 

author's osteochondral graft in, 179, 181 

autoflxation in, 177 

autologous osteochondral graft in, 179, 180, 

Billington's graft in, 179, 190 

bone-grafts in, anaesthesia during, 28 

clearly defined gaps in, 6 

complete destruction in, 123, 158, 168 

dental splints in, 177, 195 

estimation of loss, 5 

extensive loss in, 70 

fracture, drainage of, 6, 7 

grafting in, methods, 177-189 

ilium graft in, 178, 179, 180 

non-union in, 179 

osteogenesis in grafts in, 34 

osteoperiosteal grafts in, 177, 180 

pedicle graft in, 178, 180 

prosthetic replacement in, 158 

re-creation of labiogingival sulcus in, 9, 182 

rib-grafts in, 177, 179 

summary of principles of grafting in, 180 

tibia grafts in, 178, 179 

union in, 70 

Massage, dispersal of oedema by, 34 
Mastication, essential problem in palatal injuries, 

205, 206 
Mastoid process, adhesion of remnants of pinna 

to, 387 

Mattress sutures in cheek injury, 57 
Maxilla, anaesthesia during operations on, 24 

artificial, 89 

double fracture with downward displacement, 
227, 229 

downward displacement of, 203 

extensive loss of, cases illustrating, 197, 198 

falling in of soft tissues due to extensive loss, 

forward rep'acement of, 195 

fractures involving orbital plate, 203 

loss of orbital plate of, 301 

prosthetic appliances for, 203 

prosthetic replacement of, cases illustrating, 
196, 198, 199 

Maxilla, replacement of, 227, 229 

superior, loss of, 62, 64 
cases illustrating, 64-74 
prosthetic replacement of, 196, 198 

See also Pre-m axilla 
Meningocele, 393 

Metallic plates, for building up facial contour, 12 
Methylated spirit, preparation of skin for opera- 
tion by, 29 
Microstoma, 133, 144 

causes of, 123 

facial burns, 123 

post-operative, 8 
Moustache, bridge pedicle flap for, 114 

flaps providing, 79, 90 
Mouth injuries, 193 

avoidance of secondary haemorrhage in, 7 

anaesthesia during operations in, 23 

cavity lined by Thiersch graft, 200 

contraction in, 123, 144 

dental splint in, 10 

depression of corners in, 77, 90, 91 

destruction of corners in, 62, 130 
cases illustrating, 130-133 

drainage from, 6, 7 

drooping of muscles in, 94 

early treatment of, 6, 7 

epithelial inlay in, 9, 10 

flaps in, 19, 43, 56, 94 

forcible replacement of palate in, 71, 72 

operation to raise corners in, 67 

prosthetic appliances in, 193-201 

provision of lining membrane in, 8 

ring-like type of, 144 
Mucosal grafts, 8 
Mucous cavities, provision of lining membrane 

for, 3, 8 

Mucous flaps, in lower lip injuries, 152, 156 
Mucous membrane, estimation of loss of, 5 

preservation of form and vitality of tags of, 6 

suture of, 6 
Mule's globes, 336 
Muscle flaps, for soft facial contour, 14 

in checking, 52, 55 
Muscle grafts, use of, 14, 16 

Nares, anterior, upward displacement of, 230 

stenosis of, following imperfect rhinoplasty, 213 
Nasal bridge, autologous cartilage graft to, 293 
cartilage imbedded over, 271 
cartilage support to, 225 
celluloid support to, 226 
depression or destruction of, 201, 222 

cases illustrating, 223-229 

prosthetic support for, 202, 203 
excessive prominence of, 398 
loss of middle portions of, 230 

cases illustrating, 231-245 
loss of upper half of, 217 

cases illustrating, 216, 218-221 
loss of upper quarter of, 214 

cases illustrating, 215-216 

treatment, 214 
raising of, 232 

Nasal flaps, in upper lip injuries, 90 
Nasal reconstruction, author's method, 233 



Nasal splint, with dental fixation, 201 

with extra-oral fixation, 202 
Nasal stenosis, post-operative, 8, 213 

treatment of. 213 

Nasal lul>c, administration of anaesthetics by,25, 28 
Naso-labial flaps, 19 

in lower lip injuries, 121, 142, 148, 130, 154 
Near-far far-near suture, 32 
Neck, liurns of. 317 

fragments of mandible in, 70 
Neck-flap, ascending, 19 

for lower lip injury, 159 

Nelalon method of obtaining cartilage, 13, 14 
Nose, arrested development from natal injury, 399 

artificial, 211 

complete atresia of, 280 

deformity following lupus, 400 

external covering of, 213 

hereditary disease of, 396, 397 

lining membrane of, 211 

syphilitic, 392 

traumatic deformity of, 399 
Nose injuries, 211-214, 217, 222, 230-246, 258 

advancing flaps in, 248 

air-way restored by prosthesis, 202 

ala loss in, 246 

cases illustrating, 247-257 

aiuesthcsia during operations, 24, 27 

backward displacement in, 87 

bone cartilage transplant from rib in, 228 

burns, 347 

cartilage implants in, 219, 223, 227, 234, 264, 

266, 268, 399 
cases illustrating, 215-298, 396-400 

clearing of air-way of, 213 

complete loss of bony and cartilaginous 
support, 230 

depressed fractures, 392 

displacement upwards, 201 

epithelial lining in, 221 

establishment of air-way in, 271 

flaps in, 212, 219, 234, 248, 257, 275, 283, 296 

forehead flaps in, 396 

Indian type of, 246 
cases illustrating, 257 

infra-oral and extra-oral appliances in, 201 

laceration of soft and hard tissues, 200 

lateral displacement, appliance for, 201 

loss of lower half, 263, 270 

loss of lower portion of nasal supports, 224 

loss of lower two-thirds, 280, 285 

loss of tip in, 212, 246, 249, 267, 269, 398 
cases illnsl rating, 247-257 

lower third, 246 

author's method of treatment, 258 
cases illustrating, 247-257 

observations on, 211 

obstructed air-way in, 202, 203 

partial destruction of floor in, 84 

pedicle Maps in, 2 13, 245, 257, 261, 275, 283, 2!i(i 

prosthetic appliances in, 200-203 

pug-nose deformity, 211, 230, 231 
cases illustrating, 232, 237-239 

reconstruction in, author's method, 233 

relaxation button in, 220 

replacement upwards and forwards in, 88 

retention apparatus in, 225 

Nose injuries, scalp-flaps in, 236, 239 

skin lining for the bridge and also, 212 

skin cartilage Haps retaining tip in position, 
212, 272 

skin-grafts in, 246, 295 

sub-total loss in, 274 

support for lacerated tissues in, 201, 203 

surgical replacement of lacerated tissues in, 201 

suture in, 219, 220, 250, 272 

total loss in, 259 
except ala and columella, 290 
with maxillary and cheek loss, 294 

traumatic deformities, 397-399 

turbinate grafts in, 291, 292, 295 

upward displacement of tip, 230 

Vallancey swing in, 230, 231 

See also Nasal bridge ; Hhinoplasty 

Obturator, use of inferior turbinate as, 207 
(Edema, affecting skin-flaps, 22 

dispersal of, by massage, 34 
Oil-ether anaesthesia, 27, 28 
Operations, stages of, 29 

technique, 28 

treatment after, 34 
Optimum scar, factors necessary for production 

of, 33 
Orbicularis palsy, conditions due to, 344 

operation for, 344 

Orbit, epithelial-lined cavity in, 336 
Orbital cavity, epithelialisation of, 203 
Orbital plate, loss of, 301 

maxilla fractures involving, 203 
Orbital ring, injuries of, 301 

cases illustrating, 302-315 
Oro-nasal communication, restoration of, 206 
Osteochondral mandible graft, 180 
Osteoperiosteal flap turned down from glabclla, 

Osteoperiosteal repair of fractured mandible, 

177, 178, 183-185 

Oxygen and chloroform anaesthesia, methods, 

Palate, deficiency of, protection of tongue from 

sutures in, 204 

forcible replacement of, 71, 72 
injuries to, 205 

anterior perforations, 16 
classification of, 206 
dental aspect of, 205, 206 
diagnosis of, 206 
extensive loss in, 71 
flaps in repair of, 207 
mastication during, 205, 206 
method of repair, 207 
prosthetic appliances in, 205 
recently sutured, protection from tongue move- 
ments, 204 

soft tissues adhering to, 206 
I'alpebral fissure, closure of, 344 
Paraffin wax, for building up missing contour, 12 
Paraldehyde, anaesthesia by, 28 
Paralysis of orbicularis muscle, 344 
Pedicle, return of, 29 

Pedicle bone-graft, in mandible injuries, 178, 180, 



Pedicle flaps in eye injuries, 309, 358, 362, 365, 369 

in nose injuries, 212, 243, 245, 257, 261, 275, 

283, 296, 400 
Petrol burns, 347 
Pre-maxilla, destruction of, 90 

loss of, 16, 83, 285 

prosthetic replacement of, 92, 195, 106 

total loss of, 84 
Principles of plastic surgery, 4 
Prosthetic appliances, 193 

for loss of bone, 200 

in chin injuries, 172, 174 

in eye injuries, 203-205, 335-337 

in maxilla injuries, 196, 198 

in mouth injuries, 193-200 

in nose injuries, 200-203, 212 

in palatal injuries, 205 

in upper lip injuries, 88 

intra-oral and extra-oral, 201-203 

object and use of, 193 
Ptosis, 326 
Pug-nose deformity, 211, 230, 231 

cases illustrating, 232, 237-239 

standardised treatment of, 231 

Radiographic examination, necessity for, 5 
Restoration of contour, 12-14, 193-195 
Restoration of tissue, planning of, 7-10 
Rhinophyma, 392 
Rhinoplasty, 211 

advance in the study of, 211 

advancing flaps in, 214 

anaesthesia during, 23, 27 

author's methods, 212, 213 

blepharoplasty with, 314 

cases illustrating, 215-298, 396-400 

early methods of, 3 

flaps in, 19, 211, 213 

forehead flaps in, 396 

from the chest, 212, 213 

grafting of raw area on forehead after, 18 

historical observations, 3 

imperfect, nasal stenosis following, 213 

in cases of lupus, 391 

incisions for, 274, 281 

Indian type of, 291 

lining membrane in, 8, 211 

principles of, 211 

stages of the operation, 29 

supporting structure in, 212 

temporal artery tube pedicle flap in, 400 

total, case illustrating, 259 

turbinate grafts and muco-cartilaginous flaps 
in, 16 

ulcerative processes affecting, 8 

Vallancey swing in, 214, 230, 231 

See alxo Nose injuries 
Rib, ansesthesia for operations on, 27 

bone cartilage transplant from, 228 

cartilage from, in nose injuries, 231 

in pinna injuries, 383 
Rib -grafts, 183-189 

to the mandible, 177, 179, 181 

Scalp-flap, in chin injuries, 170 
in nose injuries, 236, 239 
in upper lip injuries, 78, 79 

Scars, cause of, 6 

depressed, fat-flaps for, 14 

due to burns, 348 

excision of, 30 

in chin injuries, 164, 167 

in lip injuries, 135-137, 141, 143 

following eye operations, 321 

function impeded by, 30 

in eye injuries, 302 

invisible, 32 

of the cheek, 37-41 

excision and incision of diagrams illustrating, 
61, 63, 65, 69 

optimum, factors necessary for production of, 

prevention of, 6, 28 

Shipway's warm ether apparatus, 27, 28 
Shock, prevention of, during operation, 29 
Sitting-up position during anaesthesia, 24 
Skin cartilage flaps, in rhinoplasty, 212, 272 
Skin-flaps. See Flaps 
Skin-grafts, 16 

for burns, 348, 349 

in building up missing contour, 12 

in eye injuries, 314, 315, 332, 344 

in nose injuries, 246, 295 

in pinna injuries, 383 

indications for, 16 

preparation of areas for, 29 

thickness of, 18 

when preferable to flaps, 22 
Skin, preparation for operation, 29 
Speech, loss of, in jaw injuries, 124 
Star-shell burn, 254 
Stent, holding Thiersch graft, 287 

how held in position, 197 
appliance for, 197 

use of, 10 

Subcutaneous fat-flaps, 30 
Sulcus, deepened, lining membrane for, 9 

dental, preservation and formation of, 194, 195, 

stent impression of, 10 
Supporting structures, 12 
Suppuration, early cutting of flaps predisposing 

to, 6 
Suture, early removal of, 33, 34 

factors during, 33 

forceps for, 31 

in cheek injuries, 63, 65 

in chin injuries, 157-163, 164, 167 

in eye injuries, 302, 308, 323 

in inferior blepharoplasty, 315 

in lip injuries, 84, 242 

in lower lip injuries, 125, 130, 141, 149, 150 

in nose injuries, 219, 220, 250, 272 

in pinna injuries, 383, 384, 385 

in upper lip injuries, 93, 97, 101, 103 

material for, 31, 32 

mattress, in cheek injury, 57 

near-far far-near, 32 

subcuticular, 32 

technique, 31-33 

wire-retention, from cheek to cheek, 219 
Syphilis, 13 

nasal supports in old cases of, 212 
Syphilitic nose, plastic treatment of, 392 



Tagliacozzi method of rhinoplasty, 3 

Tattooing of eyelids, 329 

Teeth, carried through the cheek, 50 

injuries to, 207 

loose and septic, clearing of, 6 

loss of, 193 

preservation in good occlusion, 195 

suspensory wiring of fragments of, 7 
Temporal artery scalp-flap, 78, 400 

for upper lip injuries, 79 
Temporal llap, in eye injuries, 34, 308 
Temporal Haps, in lip injuries, 77 
Temporal muscle flaps, 74 

in check repair, 52, 55 

in molar injury, 58 

Tension, avoidance of, on apposing sutures, 33 
Tliiersch grafts, g 

cases suitable for, 16 

in blepharoplasty, 313 

in eye injuries, 336 

in mouth wounds, 10 

in pinna injuries, 386 

oral cavity lined by, 200 

stent holding, 287 
Tibia grafts, in nose injuries, 217 

to the mandible, 178, 179, 183-185 
Tissue fluids, skin-flaps and, 22 
Tissue irritants, 12 
Tissues, damaged, replacement in normal position, 

undue stretching of, 6 

estimation of distortion of, 5 

estimation of loss of, 5 

hard, displaced fragments of, 194 

materials and appliances irritating, 12 

Tissues, normal, early replacement of, 5 

replacement of, 12, 193 

restoration of, planning of, 8 

See also Bony tissue 
Tongue, protection from sutures in operations on 

palate, 204 

Trachea, blood entering, 27 
Tracheotomy, 26 
Transposed flaps, 19-20 
Treatment, early, 5 

principles of, 5-7 

indifferent, causes of, 4 
Tripier operation, 59 

Tube pedicle rhinoplasty from chest, 213 
Tubing of skin-flaps, 19, 21, 213, 393 
Turbinate, inferior, in palatal injuries, 207 

inferior, use as partial or complete obturator, 

Turbinate grafts, 291, 292, 295 

Ulcerative processes, following rhinoplasty, 8 
Ulcers, plastic treatment of, 393 
Urethra, stricture of, 393 

Vallancey swing, in rhinoplasty, 214, 230, 231 
Venous stasis, 22 
Vulcanite nasal support, 276 
Vulcanite plates, building up of missing contour 
with, 12 

Wax, in building up of missing contour, 12 
Wolfe graft, 16 

in ala injuries, 247 

to forehead, 273 

relieving ectropion, 366 

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